Navigating the Complexities of Coverage and Care
Hidden Costs and Controversies: The recent tragic murder of a UnitedHealthcare CEO has reignited public outrage toward the health insurance industry. Many see insurers as profit-driven entities that deny necessary care, but the reality is far more nuanced.
Having spent my career in non-profit health care, I transitioned to the insurance industry in 2018 out of curiosity. I wanted to understand how insurers operate and whether their decisions align with patient needs. As a registered nurse case manager, I participated in approvals, denials, and medical reviews. Contrary to public perception, decisions followed clinical guidelines and medical reviews by physicians. Working for a Blue Cross Blue Shield plan, I saw no malice or profit-driven motives—just a structured, regulated process.
The Reality Behind Insurance Decisions
Many people don’t realize that employers choose specific benefit options, shaping what an insurance plan covers. For example, when a member demanded coverage for a service dog, I couldn’t approve it because their employer had not selected it as a benefit. The system is filled with hidden traps, unexpected costs, and confusion over whether to blame insurers or the broken system itself. Hidden Costs and Controversies
I experienced these challenges firsthand as a heavy user of health insurance. My out-of-network provider raised rates 83% to $550 per visit. My insurer demanded medical records, took six months to process my reimbursement, and ultimately pushed me to switch doctors. Consumers often feel abandoned in these situations, with no real advocate on their side.
The Hidden Costs That Surprise Patients
Many patients fall victim to unexpected costs, from exorbitant ambulance fees to Medicare’s $1,600 deductible for hospital stays. These financial burdens contribute to the fact that two-thirds of bankruptcy cases cite medical expenses as a primary factor. Despite the Affordable Care Act’s intent to prevent financial ruin due to health care costs, many consumers remain underinsured.
Hollywood has long depicted insurers as villains. In As Good As It Gets (1997), Helen Hunt’s character lashes out at an HMO for refusing to cover her son’s asthma treatment. While dramatized, the scene reflects the frustration many patients feel. However, insurers often have strong incentives to keep patients healthy—especially when managing chronic conditions like asthma through preventive programs.
The Role of AI and Bureaucratic Barriers
In today’s system, insurers are seen as gatekeepers responsible for denying coverage to control costs. This perception worsens with increasing reliance on AI-driven call systems that make it difficult to reach a human representative. My own experience refilling my daughter’s prescription took eight phone calls over two hours due to a copay card issue—an infuriating ordeal that even tested my patience.
How to Advocate for Yourself in the System
Rather than blaming insurers outright, patients must become proactive advocates. Keep receipts, document every interaction, and remain polite yet firm in communications. If an issue isn’t resolved, escalate to the next level—whether that’s a supervisor, a state insurance commissioner, or a senator. Some employers offer advisory services to help employees navigate these challenges, so it’s worth asking about available resources.
Insurance representatives, like the rest of us, are navigating the same system with similar frustrations. They serve as the intermediaries in a complex and often impersonal process.
A Call to Action
At Stanford Physician Advocate, we strive to empower physicians and patients to challenge the inefficiencies and inequities in the health care system. Understanding the realities of health insurance—and learning how to work within its constraints—can help patients make informed decisions, minimize financial risks, and access the care they need.
Learn more about advocating for better health care at StanfordPhysicianAdvocate.org.