The recent public discourse surrounding the tragic shooting of a UnitedHealth Group CEO and broader frustrations over insurance denials has brought renewed attention to the challenges patients and providers face in navigating the current healthcare system. While acts of violence are never justified, this incident has highlighted the deep-seated anger and despair felt by many when essential care is delayed or denied.
In this context, a story shared by Marybeth Rizzo Moore, CRNP, CDCES, serves as a powerful example of the barriers that patients and providers confront daily. It underscores the urgent need for systemic change in how care is approved and delivered.
The Challenges of Insurance Denials
In her LinkedIn post, Moore described a troubling encounter with a denial for a continuous glucose monitor (CGM) for a diabetic patient who was also a breast cancer survivor. The denial came quickly, via fax, and was reinforced when the patient’s pharmacist informed her they could not provide the device. The patient faced the prospect of performing four daily finger sticks on her right hand—her dominant hand—a scenario Moore deemed far from ideal.
Securing approval required hours of Moore’s time. She had to contact the insurer, provide documentation, and advocate for the device’s necessity, ultimately winning the appeal. However, Moore noted the systemic inefficiency and its toll on clinicians and patients alike:
“Denials are automated and happen in minutes to hours based on algorithms. This process is unseen and uncompensated for providers, yet it’s now necessary to get the best care for our patients. Insurance companies are out of touch with best treatments.”
A Broader Crisis in Care
The challenges Moore describes are not unique. Automated denials and cumbersome approval processes create significant barriers to care, contributing to:
- Delayed treatments that can worsen outcomes.
- Clinician burnout, as providers spend excessive time on administrative tasks.
- Financial distress for patients, with many struggling to meet out-of-pocket costs like deductibles, copays, and coinsurance.
Research underscores the magnitude of these issues. According to the American Journal of Public Health, nearly two-thirds of bankruptcies in the U.S. are linked to medical expenses, with high out-of-pocket costs playing a central role.
A New Model of Care
Chris Barakat, Chief Commercial Officer at WOOP, responded to Moore’s story by pointing to an innovative solution:
“This is why we write our own health plans for benefits consultants to sell. We don’t have this issue. If it is medically necessary as determined by their DPC clinician, then we get it sourced the most cost-effective way possible. Members get what they need, clinicians are empowered to practice medicine and care for their patients, patients pay next to $0, and the health plan (employer) saves a ton of money.”
Barakat’s remarks reflect a growing movement to overhaul the traditional insurance model. Plans like WOOP empower Direct Primary Care (DPC) clinicians to make care decisions without interference from insurers. By removing middlemen and focusing on direct payments, these plans ensure patients receive timely, cost-effective care.
Linking It All Together
The systemic issues described by Moore—denials, out-of-pocket costs, and administrative hurdles—are symptoms of a broken system. To learn more about how these challenges affect patients and explore potential solutions, read our article “Deductibles, Coinsurance, and Copays: What Are They and Do I Need to Pay Them?”.
As Moore’s story shows, the path to better healthcare lies in empowering clinicians, simplifying access, and prioritizing the patient’s needs over bureaucratic red tape. While tragedies like the UnitedHealth Group CEO shooting are extreme, they underscore the urgency of addressing the root causes of frustration within our healthcare system. The stakes—both in lives and livelihoods—are simply too high to ignore.
