Fighting for health care claim approvals

Marketing executive Mathew Evins lived with chronic back pain for eight agonizing years. He described it as “excruciating.” By 2024, he had trouble just walking. He had exhausted non-invasive treatment, and his doctors agreed he needed surgery.

His insurance company had other ideas: “They went back to my surgeon and said, ‘Your patient needs another six weeks of physical therapy,'” Evins said.

So, Evins reluctantly complied, for six more pain-filled weeks. And even after that, his insurance denied coverage again … and again. “Emotionally, it’s like a roller coaster,” he said. “Physically, I just wanted relief.”

But no relief came. Seven months went by. His condition deteriorated. “Everybody I saw said, ‘This damage could become worse and/or permanent, if the surgery isn’t done as soon as possible,'” he said.

Twenty-seven million Americans don’t even have health insurance, so Evins had considered himself lucky … until he actually needed it. He agrees insurance companies should have a voice in coverage, “but they shouldn’t have the definitive voice.”

Most Americans agree; 73 percent say healthcare delays and denials are a major problem.

“It’s not the case that the providers are the angels and the insurance companies are the devils,” said author Katherine Hempstead. “I mean, we could do another show about hospital pricing. But I think that consumers feel like, ‘Hey, doctors are actually doing something. They’re trying to do something that they say will help me. And here is this intermediary coming in and saying that they can’t do it.'”

Hempstead, senior policy officer at the Robert Wood Johnson Foundation in Princeton, New Jersey, has seen this play out over and over again: “I just heard a story yesterday about someone who was really benefiting from taking Botox for migraines and, all of a sudden, denied.”

Jeff Witten says 20% of insurance claims – one out of five – are denied, which is a major reason why he and Ben Howard co-founded a company called Sheer Health.  “Our goal is for people to never have to deal with their health insurance again,” said Howard.

Patients can just take a picture of their bill and upload it to Sheer Health. “We’ll handle everything,” said Howard. And he means everything. Sheer Health will fight every insurance battle on behalf of every client, either for $40 a month, or for a percentage if they get money back.

“Sunday Morning” reached out for comment from AHIP, a national trade organization for health insurance companies. The group responded in part: “…health plans, providers and drugmakers share a responsibility to make high-quality care … affordable … and easier to navigate…” 

But Mathew Evins struggled in vain to get coverage for his back surgery, until he found Sheer Health.  Sheer reviewed every last word of his policy and authorization requests, submitted an expedited appeal to his insurance company, and worked with his doctor just to understand the authorization issue.

“Sheer got everything resolved,” Evins said. “And I finally had my surgery in mid-October.”

The outcome? “I’m doing great.”

Katharine Hempstead thinks Sheer Health’s success speaks to our health care system’s failure: “I think it’s sad that we need that. It’s treating a symptom, you know, which is often a good business idea, but it doesn’t make me feel like, ‘Okay, that’s all we needed.'”

She agreed it amounts to buying insurance for your insurance.

What we clearly need, with or without Sheer Health, is a system that works. According to Evins, “It’s people’s lives that these insurance companies hold in the balance. Take that seriously. You’re not their medical practitioner. Don’t act like it.”

    
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Story produced by Amiel Weisfogel. Editor: George Pozderec.