Description
ProPublica got a tip from a reader named Teressa. Her husband was having a severe mental health crisis, and her health insurance company was denying coverage for his hospital and inpatient treatment. She was fighting back against the denials — and recording every phone call with the company as she did. She brought reporter Duaa Eldeib along for the journey, which ended after Teressa was able to deploy what one source called the industry’s “best-kept secret.”
Transcript
Editor’s Note: “Paper Trail” is produced as an audio series. If you are able, we encourage you to listen to the series. Transcripts are for reference only and may contain typos. Please confirm accuracy before quoting.
Jessica Lussenhop: ProPublica. Investigative journalism in the public interest.
As a heads up, this story contains detailed descriptions of suicide attempts. Please take care while listening.
Here’s a little secret: Anybody can do investigative journalism. Say you’re facing a problem. Something that feels really unfair. Maybe you start researching, diving deep, documenting what’s happening. Maybe you find something out that other people didn’t know. Congratulations, you might be an investigative reporter.
At ProPublica, a lot of our investigations start with tips from people like you. The things people tell us can lead to some pretty wild revelations. If it turns out whatever you’re struggling with is hurting a lot of other people too, calling it out can lead to real-world change. Change that prevents anyone in the future from going through the same painful experience. It’s honestly kind of incredible.
A couple years ago, my colleague Duaa Eldeib heard from someone just like that.
Duaa Eldeib: I think it was maybe September of 2024 that we got this tip through a callout.
Lussenhop: Duaa covers healthcare and, along with some other colleagues at ProPublica, she sent out a callout to the public asking for tips. She was specifically curious about mental health, because that’s an area where people really have trouble getting their health insurance to cover treatment. She basically said, Hey, does anyone have any stories about this? And that’s when she heard from Teressa.
Eldeib: I think at the most basic level, she said that this horrible thing happened with her husband and she’s in this fight with the insurance company.
Lussenhop: Teressa’s husband was having a severe mental health crisis. She was worried he was going to take his own life, and she’d gotten him into an inpatient treatment facility.
Eldeib: And the insurance company was still denying his coverage.
Lussenhop: She was fighting them for almost $100,000.
Eldeib: That to me was just mind-blowing.
Lussenhop: Teressa reached out to Duaa because she thought the company was deliberately trying to avoid paying a legitimate claim.
Eldeib: I have heard of cases where insurance companies deny coverage, but this seemed really hard for me to wrap my head around. And so I think I really wanted to understand how this could happen.
Lussenhop: And there was one other very important thing Teressa mentioned: She had been documenting every interaction she had with the health insurance company.
INSURANCE PHONE CALL, Highmark: Do you mind holding a few more moments? If we get disconnected, I’ll definitely call you back, but I’m hoping that won’t happen again. Sorry.
Lussenhop: Recording every single phone call.
INSURANCE PHONE CALL, Teressa Sutton-Schulman: OK, sure. Yeah, I’ll hold.
INSURANCE PHONE CALL, Highmark: Tired of waiting for your EOB to come in the mail? Why not elect to receive your EOBs via email. …
Lussenhop: On these calls that Teressa sent Duaa, I feel like I’m right there with her, sitting on these endless holds. They remind me of every crappy customer service experience that I’ve gone through.
INSURANCE PHONE CALL, Sutton-Schulman: Um, so this is the third time that I’m calling back and I’m in the middle of appeal.
Lussenhop: But on these calls, Teressa is fighting for life-or-death medical care and for her and her husband’s financial future.
INSURANCE PHONE CALL, Sutton-Schulman: I also didn’t receive the information about the code that was on one of the denied benefits.
Lussenhop: And she keeps hitting all these roadblocks.
INSURANCE PHONE CALL, Sutton-Schulman: OK, well, another part of this mystery is this very same service was issued under an earlier claim number.
Lussenhop: It’s like she’s stuck in a maze.
INSURANCE PHONE CALL, Sutton-Schulman: I’ve been given an adverse benefit notification; I’ve lost an appeal that I didn’t even know was there. I didn’t have a case number, and now I’m just being told too bad.
Lussenhop: A maze that at times seemed designed to confuse and discourage her — and ultimately convince her to quit.
INSURANCE PHONE CALL, Sutton-Schulman: I will hopefully get a call by noon and, and if not, I will call back again.
Lussenhop: But she was determined to find her way out.
INSURANCE PHONE CALL, Sutton-Schulman: I would suggest you get your attorneys involved because I’m certainly getting mine involved.
INSURANCE PHONE CALL, Highmark: OK, I understand. I understand. That makes sense.
Lussenhop: Duaa started following Teressa’s journey, not knowing where it would lead. But after months of wandering around in this maze, Teressa would find a secret door. It was on Page 62 of her insurance coverage booklet.
Eldeib: Somebody told me it’s one of the industry’s best kept secrets.
Lussenhop: And in this story, we’re going to tell you that secret, because if you’re ever in a similar fight with your health insurance company, you might need to know this too.
Lussenhop: It does kind of feel a little bit like, oh, this could happen to anybody.
Eldeib: I think that’s exactly it. I think that’s exactly it, Jessica. This could happen to anybody.
Lussenhop: I’m Jessica Lussenhop. And this is “Paper Trail.”
Lussenhop: Right after reporter Duaa Eldeib read Teressa’s message about her insurance fight, she reached out.
Eldeib: So, I emailed her right away and I was like, Can we talk?
PHONE CALL, Sutton-Schulman: What would you like to know about me? Other than the chaos I find myself immersed in at the moment.
PHONE CALL, Eldeib: Uh, what about your life pre chaos? Can you just tell us a little about kinda, you know, where you live, what you do, what your life was like?
PHONE CALL, Sutton-Schulman: OK. Um, I live in Raleigh, North Carolina.
Lussenhop: Tell me a little bit about this couple.
Eldeib: So they met in college. And the night that they met, her husband walked up to her kinda trying to strike up a conversation, and she politely tells him, like, “Look, I’m waiting for someone.” And then he responds right away and he is, like, “I could be someone.” And really from that night, like, that was it, they fell in love.
PHONE CALL, Sutton-Schulman: We’re best friends on top of everything else. You know, I, I would describe our life as, as genuinely happy.
Eldeib: Teressa is kind of more introverted, um, and her husband is, like, this funny guy who can, like, work a crowd. And they end up building this software consulting company together. So then she goes back to school and she becomes a paralegal, and then she becomes their kind of in-house legal expert. They’re just these college sweethearts who built their lives together.
PHONE CALL, Sutton-Schulman: I mean, I think most people would joke, you know, we’ve been married for 15 years and we still hold hands in public. People would say, that’s so funny. And, and we’d be, like, what? And they’re, like, well, you’re, you’re still holding hands like you’re on your first date. OK!
Lussenhop: Duaa talked to Teressa’s husband, and he gave Duaa permission to let her tell his story. He didn’t want his real name or voice used, so we’re going to call him L. L started struggling with his mental health around the pandemic.
Eldeib: Which, I think is not surprising, right? We saw mental health needs go up exponentially during the pandemic. And I think the things that we least expect are what trigger it. And so I think for them it was looking for a house. That’s what really set things off.
PHONE CALL, Sutton-Schulman: He decided to buy a house in probably the craziest housing market that I can remember in my lifetime. And it was challenging. And we lost, like, two or three homes and money.
Eldeib: And I think for L, financial matters especially would cause him a lot of anxiety and stress.
PHONE CALL, Sutton-Schulman: But then he just kind of kept looking at houses. He just kept looking.
Eldeib: They find a house. But it needed work. They argued a lot. They argued about money; they argued about him not willing to go get help. That’s when Teressa starts seeing her husband unravel.
PHONE CALL, Sutton-Schulman: I just, like, I can’t do this anymore. Like, I just can’t. And we separated.
Eldeib: She was no longer able to recognize the man that she fell in love with. And so then she moves out.
PHONE CALL, Sutton-Schulman: And then that is, I guess for him, he just snapped.
Eldeib: And so then he agrees to get help and they had started him on an antidepressant, and that’s when they started to get really worried because, you know, he called the doctor and said, like: “Look, like, I’m not getting better. In fact, I’m getting worse .” And he meets with a psychiatrist and he tells him: “My heart is racing. Like, my legs feel weak, and I’m waking up at 2:30 in the morning.”
PHONE CALL, Sutton-Schulman: And he was having these really terrible nightmares.
Eldeib: And so then, uh, you know, the doctor asks him about whether or not he’s considering ending his life. And he tells him he felt anxious and hopeless but he was too scared to die.
Lussenhop: Duaa spoke to Teressa and her husband several times about what happened next. The details you’re about to hear are difficult, and Duaa thought long and hard about whether to publish them. So did our team. But the details are important. Because this is the situation that doctors from the health insurance company were evaluating to decide whether the treatment was medically necessary.
Eldeib: So two days after he met with his psychiatrist, he goes into the garage. Um, and he swallows a bottle of sleeping pills, chases them down with some bourbon.
PHONE CALL, Sutton-Schulman: And then he sat in the car, in the garage with the car running.
Eldeib: And he closes his eyes. And he thinks that’s going to be the end. Teressa calls 911 because she, she was trying to get ahold of him.
PHONE CALL, Sutton-Schulman: I went over. Immediately called the ambulance.
Eldeib: The paramedics arrive and they take him to the hospital.
PHONE CALL, Sutton-Schulman: And he was involuntarily committed at that time to like a county-level facility near us.
Lussenhop: Um, I must assume that when he starts needing this care, I don’t know that probably coverage was the first and foremost concern. What the first and foremost concern was, I’m gonna go get some help.
Eldeib: Yeah, he had great coverage. Like, he had, like, Highmark Blue Cross Blue Shield, you know, like, really good private insurance. And so I think that they had just assumed that we’ve been paying into this, and we’ve been paying our premiums, and so now when we need it, they’re going to pay us back. And then about a week later, the judge decides that he can be released to Teressa’s care, um, under two conditions: that he has to see a therapist and a psychiatrist, and that he has to move back in with Teressa. She loved him. So, of course, she agreed.
PHONE CALL, Sutton-Schulman: He was home for four days, and then one morning I woke up, he was not here.
Eldeib: So she goes downstairs, and she sees him leaning over the kitchen sink. And she walks closer to him and then she sees a knife, and it’s covered in blood. And then as she gets closer, she sees blood, like, pouring out of his neck, um, and all over his sweater and, like, coming from his wrists. And she immediately goes into, like, saving mode. And she just keeps asking, Did you do this to yourself? Did you do this to yourself? And then finally he responds and he is, like, yes.
Lussenhop: Oh my God.
Eldeib: And she calls 911 again. And she’s, you know, kind of trying to explain what’s happening and asking for help. And he tells her. …
PHONE CALL, Sutton-Schulman: Just, just let me die. Just let me die. Just leave me alone and let me die. That, that’s all he would say over and over and over.
Lussenhop: Um, are you OK?
Eldeib: I’m OK. For readers to understand how egregious it is for the insurance companies to have denied this, they have to know the details, like, they have to know how serious it was and then despite that, the insurance company still denies it.
Eldeib: So after the second attempt, he agrees to get treatment. And they send him to a residential facility. Then while he was there he starts displaying signs of psychosis, hearing voices.
PHONE CALL, Sutton-Schulman: He would call me and, and swear they were trying to frame him for being a drug addict and a murderer. I mean, it was just, it was out there.
Eldeib: Teressa is seeing that like, not only is he not getting better, he’s getting worse. So then she calls a friend who’s a social worker.
PHONE CALL, Sutton-Schulman: And I ask them, where’s the best place to go? We’ll go anywhere.
Eldeib: And so her friend recommends The Menninger Clinic in Houston. And so she books a flight for the two of them to Texas.
INSURANCE PHONE CALL, Highmark: If you are calling to precertify a mental health or substance abuse admission, press 1. Precertification …
PHONE CALL, Sutton-Schulman: I called my insurance, the first call I ever had with them, and I recorded it ’cause I’m, like, this is probably not gonna go easily to get the preauthorization to move him. Because in my coverage booklet it says I need to call first.
Lussenhop: This call? This is the moment Teressa enters the health insurance maze, months after L’s mental health struggles first began.
INSURANCE PHONE CALL, Sutton-Schulman: We want his care to be moved to The Menninger Clinic in Houston, Texas, which is both out-of-state and out-of-network for our particular coverage. But I know I have to get preapproved or precertified to do that.
INSURANCE PHONE CALL, Highmark: OK, so he’s currently in a inpatient center. …
Eldeib: At first, it seems like it’s going to be fine. Insurance gives her the go-ahead.
PHONE CALL, Sutton-Schulman: We get the letter that says this stay has been authorized.
Eldeib: And they say that he is preauthorized to get into the new hospital.
PHONE CALL, Sutton-Schulman: I’m like, all right, great.
Eldeib: So, one of the first things that they do is do this genetic testing. And it reveals that he could have an adverse reaction to the first antidepressant that his doctor, you know, had put him on. And so that for both of them felt, like, maybe that is, like, why things spiraled so quickly, so fast. They’re both kind of feeling like things are, are taking a turn for the better.
PHONE CALL, Sutton-Schulman: Then I get the first denial letter.
Eldeib: So that first denial letter was from Highmark Blue Cross Blue shield. And they were denying L’s first residential treatment facility, the one he was taken to after his suicide attempt, saying that he now has a balance of $30,000.
Lussenhop: Oh my God.
Eldeib: Um, for that care. The denial wasn’t, you know, because of some kind of, like, plan restriction. It was because doctors working for Highmark determined that the care was not medically necessary.
Lussenhop: Not long after that, Teressa got a denial for the second treatment facility. With the same justification: His care was not medically necessary. And I want to read directly from L’s denial letter because you just have to hear it for yourself. “The request for coverage for an acute inpatient psychiatric hospitalization is not approved. You reported history of depression and anxiety symptoms. You are not suicidal, homicidal, or psychotic. You are able to care for your personal needs. You are not a danger to yourself or others. Your admission is not medically necessary. You could have been safely managed at a lower level of care.” Teressa reads this and is, like, absolutely not.
PHONE CALL, Sutton-Schulman: Oh, no. Yeah, this is, this is gonna be a fight. I just feel it.
Lussenhop: Her next move is to appeal the denial.
Eldeib: And she begins tracking and documenting everything. She’s, like, taking meticulous notes, you know, she’s got file folders. Everything is really organized. Her bills, her letters, her appeals requests.
Lussenhop: And she keeps recording her calls.
INSURANCE PHONE CALL, Highmark: Please continue to hold and be assured that your call will be answered in the order it was received.
Lussenhop: In these first calls to Highmark reps, Teressa isn’t even getting to the heart of the matter: why the care was denied. She keeps running into these roadblocks.
INSURANCE PHONE CALL, Sutton-Schulman: I called in yesterday trying to get some EOBs, that we cannot download, that have been denied or not paid.
Lussenhop: Files that won’t download.
INSURANCE PHONE CALL, Sutton-Schulman: I have been trying to fax over some information regarding a claim and the fax number provided in the letter I received is, doesn’t work. It keeps giving an error.
Lussenhop: Incorrect fax numbers.
INSURANCE PHONE CALL, Sutton-Schulman: And it says the file is corrupted when you try to open it, even though it looks like it successfully downloads.
Lussenhop: Corrupted files sent over email.
INSURANCE PHONE CALL, Highmark: Did you check in your spam and your junk, all of that?
INSURANCE PHONE CALL, Sutton-Schulman: Yes. We didn’t get anything.
Lussenhop: Missing letters Highmark claims to have sent.
INSURANCE PHONE CALL, Sutton-Schulman: And when I logged into that today, all of the prior communications regarding these appeals was gone.
Lussenhop: At one point, Teressa gets a denial that has a bizarre error in it.
Eldeib: And the denial letter says, “It was determined that your newborn does not meet the criteria for coverage of an inpatient hospital admission.” And I’m, like, newborn?! Like, newborn?
Lussenhop: What in the world?
Eldeib: Yeah. I think at the beginning, Teressa was really trying to work with the representatives and kind of trying to give them the benefit of the doubt. I noticed when I was, you know, listening there were pleases and thank yous that she would add to the calls,
INSURANCE PHONE CALL, Highmark: I’ll be right back.
INSURANCE PHONE CALL, Sutton-Schulman: OK. Thank you.
INSURANCE PHONE CALL, Highmark: I’ll give you a call and let you know.
INSURANCE PHONE CALL, Sutton-Schulman: OK, great. Thank you.
INSURANCE PHONE CALL, Highmark: OK. Thank you. Bye. Thank …
INSURANCE PHONE CALL, Highmark: … you. Bye-bye.
INSURANCE PHONE CALL, Sutton-Schulman: Oh. Wow.
Eldeib: Which, you know, disappeared once we get later into the process.
INSURANCE PHONE CALL, Highmark: How are you doing today?
INSURANCE PHONE CALL, Sutton-Schulman: Um, I’ve been better. Yeah.
INSURANCE PHONE CALL, Highmark: I, I understand.
Eldeib: The thing about Teressa is she’s a bulldog.
INSURANCE PHONE CALL, Sutton-Schulman: I never got any notice of any other appeal being accepted. I never got a case number.
Eldeib: Right? She is not someone who is going to let insurance win.
INSURANCE PHONE CALL, Sutton-Schulman: So this kind of seems like it’s by design at this point to avoid paying behavioral health claims. That’s what it feels like.
INSURANCE PHONE CALL, Highmark: Yeah. I understand your frustration. I, I get where you’re coming from.
INSURANCE PHONE CALL, Sutton-Schulman: So what is my remedy?
Eldeib: There was one call where the representative was like, oh, you didn’t get that letter?
INSURANCE PHONE CALL, Highmark: So even like acknowledgment letters, you say you’re, you said you didn’t receive those either?
INSURANCE PHONE CALL, Sutton-Schulman: Oh, I absolutely didn’t.
Eldeib: And then she just, she gets really, really, really upset.
INSURANCE PHONE CALL, Sutton-Schulman: So it’s up to me to do the, to handle the appeal, which it’s very hard for me to do when there are roadblocks being purposefully erected for me, such as not being notified that I have a case number and that I’m supposed to send stuff in and I’m on a deadline. Because I absolutely would’ve sent that stuff in. I have it.
INSURANCE PHONE CALL, Highmark: Mm-hmm.
INSURANCE PHONE CALL, Sutton-Schulman: I am very curious under what scenario exactly a person who has tried to kill himself twice within the span of a week is denied an inpatient behavioral health treatment when every doctor that saw him said he used to be in a residential treatment program. I am infinitely curious what credentialed individual made that decision that that is not medically necessary.
INSURANCE PHONE CALL, Highmark: Yeah, I, I, I definitely understand that’s very frustrating. Um.
INSURANCE PHONE CALL, Sutton-Schulman: No, that isn’t just frustrating. That is criminal. That isn’t just frustrating, that is criminal. That is a breach of agreement for services that are, that is many things.
Eldeib: And Teressa was like, oh hell no. Like, not only am I gonna appeal, I’m gonna keep appealing, keep appealing, keep appealing. And then, as she’s, like, reading the coverage booklet, which, you know, I’ve never done before, like, read an entire, like, insurance company’s coverage booklet.
Lussenhop: Me neither.
Eldeib: But she, like, she read it from start to finish.
Lussenhop: And deep in the booklet, that’s where she finds it, a way out of the maze. Something called an external review.
Eldeib: And that’s kind of like this light bulb.
Lussenhop: This is it. The secret door. An escape hatch from the labyrinth of denials, lost paperwork and endless customer service calls.
Eldeib: So we know about the regular appeals, right? When an insurance company denies you, then you can go back to the insurance company and appeal it and say, you know, look, I think that you made the wrong decision, here’s why. The external appeal or external review goes outside the insurance company. If the insurance company has already determined, you know, once or sometimes twice that they’re not going to pay for treatment, then maybe, consumer, it would be helpful for you to go to someone independent of the insurance company, have them look at all the medical evidence and see if they decide the same thing. But they’re so rare because I think most people don’t know about them. It’s, you know, somebody told me it’s like one of the industry’s best-kept secrets.
Lussenhop: Turns out this “external review” was mentioned not only in the coverage booklet, but also in Teressa’s denial letters. But then …
INSURANCE PHONE CALL, Highmark: That letter is incorrect. I guess it’s just a standard letter.
INSURANCE PHONE CALL, Sutton-Schulman: OK, so the letter I just got that says I now have a right to ask for an external independent review is wrong?
INSURANCE PHONE CALL, Highmark: Yes. Mm-hmm. Yeah, that’s just a generic letter.
Eldeib: She’s, like, what do you mean? And so, of course, she fights them on it.
INSURANCE PHONE CALL, Highmark: The rights have been exhausted, unfortunately.
INSURANCE PHONE CALL, Sutton-Schulman: How have they been exhausted when I’ve never asked for an independent outside review when it says I have the right for that in my coverage booklet. That’s the part I don’t understand. I don’t know how I’ve exhausted something I haven’t used.
Eldeib: And then they tell her, they tell her, OK, fine, we’ll let you file one, but you know, you have to get it to us before, you know, 5 p.m., which was, I wanna say, like, less than, like, two hours from when when she was on the phone with them and she, she was, like, “OK, I see you.”
INSURANCE PHONE CALL, Sutton-Schulman: OK? OK. Um, I will get that to you before 5 o’clock for sure.
INSURANCE PHONE CALL, Highmark: OK. Sounds good. Thank you so much.
INSURANCE PHONE CALL, Sutton-Schulman: Mm-hmm.
INSURANCE PHONE CALL, Sutton-Schulman: Bye.
Lussenhop: Duaa read a study that found only about 1 in 10,000 patients eligible for an external review actually uses one. Teressa was the 1 out of 10,000 people who asked to pass through the secret door.
Eldeib: So, she files this request for an external review. And it goes to a third party.
Lussenhop: After filing the external review, Teressa saw a missed call on her phone from that third party.
INSURANCE PHONE CALL, Sutton-Schulman: And I thought, oh, well, maybe they need something.
Lussenhop: The reviewer left her a voicemail. And when Teressa listened.
INSURANCE PHONE CALL, Sutton-Schulman: I was, I was just kind of shocked.
Eldeib: Had it not been for this doctor, the outcome could have been completely different.
Lussenhop: That’s next.
Lussenhop: So Teressa has filed this external review. Does not have high hopes, and then she gets this voicemail. So who called her? Who left this voicemail?
Eldeib: The call was from a doctor she’s never heard of or talked to before. His name is Dr. Neal Goldenberg. He’s a psychiatrist from Ohio who works part-time as an external reviewer, and he was the one who was assigned her case. So I called Dr. Goldenberg. And he told me the email took him by surprise.
PHONE CALL, Dr. Neal Goldenberg: It immediately jumped out at me that there was this, like, highly organized summary from a family member. And that’s not usually the case when I get these.
Eldeib: And he starts going through it, and he automatically could tell something was different about this. A lot of the reviews that come in are usually from hospitals or doctors. And then also just how meticulous it was.
PHONE CALL, Goldenberg: The information was presented as sort of like exhibit A, exhibit B, and I’ve never seen that type of language outside of, you know, court shows, lawyer shows.
Eldeib: And so, for Dr. Goldenberg, he’s, like, was this a lawyer? And then he goes to the bottom of the letter and he sees Teressa’s name and then he decides, you know what, I’m gonna call her.
PHONE CALL, Goldenberg: It was just … that just seemed like the right thing to do.
Eldeib: Dr. Goldenberg believes deeply in people getting the care that they need. He went to medical school, and he reads the book by Dr. Patch Adams, which I don’t know if you remember, I’m old enough to remember when the movie came out. But, you know, he’s that doctor.
Lussenhop: Of course I remember.
“PATCH ADAMS” MOVIE CLIP, Robin Williams: What’s your name?
“PATCH ADAMS” MOVIE CLIP, Cameron: Cameron.
“PATCH ADAMS” MOVIE CLIP, Williams: Hi Cameron, I’m Patch.
Eldeib: He’s the doctor that was played by Robin Williams. And, you know, he was really fixated on kind of infusing humor and compassion in medicine without any care whatsoever for insurance. So Dr. Goldenberg reads his book, and he’s inspired.
PHONE CALL, Goldenberg: You know, vast swaths of our population were uninsured. And so, you know, I just couldn’t get over how unfair that was. And I wanted to be part of the good guys fighting to change that.
Eldeib: He decides to specialize in community psychiatry. But he’s also a doctor. His wife’s a doctor. They had huge amount of debt from medical school that they were, like, OK, maybe a side job could also, you know, help.
Lussenhop: So like a side hustle.
Eldeib: Yeah, basically. He decides to kind of take on this side job as a third-party reviewer and he made sure to, to tell himself like, if I feel pressure to only side with the insurance companies, like, I’m out, So this is who he is at his core.
Lussenhop: This is who he is when this email presumably lands in his lap.
Eldeib: Yes. Yes. Yep. Exactly.
Lussenhop: So what did Dr. Goldenberg make of the fact that L’s care was denied based on medical necessity?
Eldeib: I mean, I think as a psychiatrist when you’re reading all of this medical evidence and you’re reading what the doctors are saying, I think he was really taken aback that this was still denied. I think it’s the same reaction that a lot of us have when we hear this story, but I think we have it more maybe from an emotional perspective. He, like, actually has the medical training to back it up and saying no, this was unfair, the claim should have been covered.
PHONE CALL, Goldenberg: I couldn’t just see it as a case on a sheet of paper. You know, I knew he was this man who had a wife that loved him enough to put an inordinate amount of work into advocating for him. And I wanted them to know that somebody cared about that.
Lussenhop: I think there’s some. … I just wanna make a note of it that there is something so fascinating about, like, at the end of this very inhuman, bureaucratic process, at the very end of this sort of, like, vortex, someone like Dr. Goldenberg’s on the other end.
Eldeib: I think that’s exactly right. In the voicemail he says very plainly at the beginning, “Hello, my name is Neal Goldenberg.”
VOICEMAIL RECORDING, Goldenberg: Hello, my name is Neal Goldenberg. I am reviewing …
Eldeib: I’m reviewing an insurance claim for your husband, and then he went on to tell her that he’s read the extensive paperwork that she provided and he wanted to let her know that he sees her. And he sees how ridiculous the system has been to her, and he told her that he was gonna approve the appeal, and he thanked her for all of her hard work.
PHONE CALL, Sutton-Schulman: I was just kind of shocked, um, honestly, that someone cared enough to call and, um, took the time to read everything I had put together.
PHONE CALL, Eldeib: Was there a part of you that thought, like, Highmark could somehow still override this or, um …
PHONE CALL, Sutton-Schulman: Yeah. Yeah. Like, I, I had to, I’m, like, yeah, and I need to make sure that this is binding on Highmark. If there’s any way at all they could disagree with this, I’m sure they will.
Eldeib: I think that’s what’s so powerful about these external reviews is that the determination is binding. So whatever the third-party reviewer decides, that is legally binding, and so the insurance company cannot argue and cannot appeal. And what experts told me is that’s also part of the reason that these external appeals are not as well known because if the external reviewer decides in your favor, then that’s it.
PHONE CALL, Sutton-Schulman: And I think, you know, like, I did call them once I got the letter and said, I got this letter, you know, what are, what comes next? And …
PHONE CALL, Eldeib: Yeah.
PHONE CALL, Sutton-Schulman: On the phone they go, oh, well yeah, we’ll be processing the payments over the next week or two.
PHONE CALL, Eldeib: Now that you won the appeal, I mean, is this the point where you’re, like, now I need to, like, get back to our, our life and our relationship?
PHONE CALL, Sutton-Schulman: Yeah, I mean that was kind of my thought at that point, was I can finally, uh, rest.
Lussenhop: This is supposed to be the magic moment. Teressa solved the maze. To Dr. Goldenberg, she had definitively proved her case: The insurance company was wrong. But, I was surprised when I heard this call of Teressa telling Duaa about it. She does not sound like a woman who just beat the hardest level of our American healthcare game.
PHONE CALL, Sutton-Schulman: I’m tired. I’m still tired, actually today just, it, it was exhausting both mentally and physically. I have had no time to process really anything that happened. Because I’ve just been running from one fire to another.
Lussenhop: Affordable Care Act insurers, the big ones like Blue Cross and Cigna, deny an average of 1 in 5 claims. For some, it’s 1 in 3. Less than 1% of people actually appeal those denials. A tiny fraction of those people will get far enough in the maze for an external appeal.
Eldeib: Most people don’t appeal because it’s a pain and because it takes a lot of time and you’re already exhausted and you’re already dealing with a million other things. So in talking to insurance experts, what they advise is appeal, appeal, appeal, appeal, appeal.
Lussenhop: Duaa asked to interview representatives of Highmark Blue Cross Blue Shield about all of this. They didn’t make anyone available to talk, but they sent a statement saying that they were complying with all state and federal laws pertaining to their members’ mental health services. L also sent the company written permission to speak about his case with Duaa, but they did not answer her questions in their response. They wrote they take their members’ experience “seriously.” “We recognize and sincerely regret however any times when the prior authorization and claims processing experience can be challenging and frustrating, even when patients are treated and claims are paid — as was true in this particular case. We also acknowledge that small errors made by physicians and/or members can lead to delays and initial denials, which are corrected on appeals, as we believe may have been the case here.”
L’s whole treatment, all the hospitalizations, would be billed at more than $220,000. Teressa and L had initially been charged and had to pay more than $95,000 of that out of pocket. But in the end, after Dr. Goldenberg’s determination, Highmark reimbursed them $70,000.
Lussenhop: So this story makes you think like, oh, this is, like, a magic, it sounds like a silver bullet. It sounds like a, a magical spell that you can cast on this whole process, or something that everybody should know about this and be doing it. Is that, is that real?
Eldeib: I don’t think so. I think for this outcome to have happened, so many things had to align, right? Teressa had to be this, you know, paralegal-background wife who is super determined and does not give up and basically spends months and months working on this appeal. And then I think the review has to land in an inbox like Dr. Goldenberg’s, someone who really takes the time to read and weigh the medical evidence before making a determination. And what I have heard from some experts in the field is that, like, that’s not always the case with external reviewers. Some of them are rubber stamps for the insurance company.
Lussenhop: That’s what really stuck with me about Teressa and L’s experience. You fight all these fights. You play the game. You try to follow all the rules through the maze. You even find the secret door. And then, the person waiting on the other side of that door? It’d better be Patch Adams.
Lussenhop: Where are Teressa and L now? How are they doing?
Eldeib: So I think there is, like, this temptation to walk away feeling, like, and they lived happily ever after. And I think I kind of was feeling that a little bit like, oh, great, well you guys got reimbursed. L, you know, got discharged. He’s back at work. He, you know, finished his treatment. Like, everything is great! But I think they’re still trying to put, you know, the pieces of their marriage back together.
PHONE CALL, Sutton-Schulman: We couldn’t really work on us because my focus was getting these appeals approved and these claims paid.
Eldeib: The two of them went back to couples counseling, um, because I do think they still love each other very much, but this takes a toll.
PHONE CALL, Eldeib: Has there been any more talk about, like, what the future will hold for the two of you?
PHONE CALL, Sutton-Schulman: Um, I, you know, I guess in our couple session that was sort of why we were there?
PHONE CALL, Eldeib: Yeah.
PHONE CALL, Sutton-Schulman: Like. what are, what are we doing now? But I, I believe the step now is, um, I have to process all the trauma. Because I haven’t done that. I’m just now starting to do that. Because I finally feel like I don’t have any insurance to fight. And, and can now take the time to do that. It’s just like, we’ve been on hold.
Lussenhop: Teressa’s tip led us to information that could help a lot of people. Duaa wrote a whole story on how you can file an external appeal and what denials are eligible. You can find the link in our show notes. If you have a tip, something you know about that you think we should look into, or something that might lead to information that could help other people, reach out to us! Go to propublica.org/tips to find out how to contact us securely.
And finally, if you or a loved one is experiencing a mental health crisis, you can call the suicide hotline at 988.
Just a heads up, we will be off next week but back the week after with a whole new episode. Thanks for listening.
Gabrielle Berbey: This episode was produced by me, Gabrielle Berbey, and edited by Katherine Wells. Engineering and sound design by David Herman. Music by Julian Sartorius, Filippo Ansaldi and Simone Sims Longo, with additional music from Epidemic Sound. The rest of our team is Julia Longoria and Sabby Robinson.
