Fighting for health care claim approvals

Marketing executive Matthew Evans lived with chronic back pain for eight agonizing years. Is there a way to explain to somebody who's never experienced this sort of pain what that's like? In a word, 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.

So Evans 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. 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.

27 million Americans don't even have health insurance. So Evans had considered himself lucky until he actually needed it. Well, you're not arguing that the insurance company shouldn't have a voice in this? No, but they shouldn't have the definitive voice.

Most Americans agree. 73% say health care 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. I mean, we could do another show about hospital pricing. But I think that for consumers-- consumers feel like, hey, doctors are actually doing something. They're trying to do something that they say will help me. And here's this intermediary coming in and saying that they can't do it.

Author Katherine 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. 20% of claims are denied, 20%. Ooh, that's a lot. That's one out of five.

--which is a major reason why Jeff Whitten and Ben Howard co-founded a company called Sheer Health. We built this company for patients. You can just take a picture of the bill and upload it to Sheer Health. We'll handle everything.

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. Our goal is for people to never have to deal with their health insurance again.

We 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." You two.

But Matthew Evans 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 request, submitted an expedited appeal to his insurance company, and worked with his doctor just to understand the authorization issue. Sheer got everything resolved. And I finally had my surgery in mid-October. How are you doing? I'm doing great. A year ago, could you have done this? Could you have just gone out and walked down the street? I could have walked for maybe 10, 15 steps.

Katherine 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, which is often a good business idea. But it doesn't make me feel like, OK, that's all we needed. This seems to amount to buying insurance on your insurance. Kind of.

What we clearly need, with or without Sheer Health, is a system that works. 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. [MUSIC PLAYING]