The Price of Denial: A Personal Finance Guru’s Battle Against the System

Note: Transcripts for “An Arm and a Leg” are generated via speech-recognition software and may contain inaccuracies. Please utilize this transcript as a reference and verify against the corresponding audio before quoting the podcast.

Dan: Greetings. Allow us to introduce someone.

Ron Lieber: My name is Ron Lieber. I am the author of the “Your Money” column for The New York Times, a writer of various books, and a resident of Brooklyn, New York.

Dan: Ron possesses a renowned expertise in navigating and optimizing financial systems to minimize expenditures. His most recent publication, concerning the financing of higher education, has been a frequently consulted resource in my household.

It is plausible that Ron is not the most prominent journalist within his own family. A significant Hollywood motion picture produced a few years ago featured Zoe Kazan portraying Ron’s wife, Jodi Kantor.

Zoe Kazan as Jodi Kantor: Hello. We are representatives of The New York Times. My understanding is that you previously worked for Harvey Weinstein.

Dan: She was among the investigative journalists whose work brought to light the history of sexual misconduct by film producer Harvey Weinstein, catalyzing the Me Too movement. This accomplishment is undeniably substantial.

In the year 2024, Jodi received a diagnosis of breast cancer, and her surgical procedure at Memorial Sloan Kettering was scheduled for a Monday morning in December.

Ron Lieber: She conscientiously followed all the preparatory steps recommended for surgery: she engaged in meditation for a week, meticulously managed her professional responsibilities, and took a brief retreat with friends.

Dan: Consequently, on the Saturday preceding the surgery, while Jodi was away with her companions, Ron spent the day with their nine-year-old child, engaged in father-son activities.

Ron Lieber: Upon our return home, I encountered a stack of mail. After seeing the child to bed, I began sorting through the correspondence, and discovered a substantial envelope from United Healthcare.

Dan: Mr. Lieber indicated that he immediately harbored suspicions regarding the contents of the envelope, anticipating unfavorable news concerning the upcoming surgery.

Ron Lieber: Indeed, upon inspection, the document contained pages of complex jargon. However, the cover letter clearly indicated a partial denial of coverage, signifying that we had, in essence, failed to meet the criteria for prior authorization.

Dan: Prior authorization. The term sounded familiar. He conducted a swift search to orient himself and quickly ascertained that this was a widespread issue affecting millions annually, though it had never personally impacted him until then.

Ron Lieber: At this juncture, a multitude of thoughts flooded my mind.

Dan: Initially, he experienced professional embarrassment. As a personal finance columnist for The New York Times, he questioned how he could have overlooked a phenomenon that caused such significant financial strain for numerous individuals.

Ron Lieber: I experienced a sensation akin to my reaction in 2008.

Dan: This was in reference to the financial crisis, which he had not foreseen.

Ron Lieber: Back in 2008, the internal dialogue was essentially: “Ron, why did you not thoroughly familiarize yourself with mortgage securitization prior to this point?”

Dan: This time, the issue was prior authorization. Mr. Lieber managed to forgive himself promptly and shifted his focus to more immediate concerns.

Ron Lieber: My primary objective was to determine how to convey this information to Jodi.

Dan: The question arose: would he disrupt her carefully cultivated pre-operative tranquility? And secondly: what was the extent of their potential financial exposure?

Ron Lieber: Should we still attend the scheduled surgery? What are the potential worst-case scenarios? Consequently, I began performing mental calculations, estimating the standard cost for such a procedure, which I surmised to be in the range of $150,000 to $200,000.

Dan: Indeed, a substantial sum. This is the point at which many individuals would elect to postpone their surgical procedures. However, Ron meticulously examined the documentation and discerned that the denial appeared to be an error. United Healthcare was not disputing the reconstructive component of Jodi’s surgery, which would be performed by a plastic surgeon; rather, they were denying the mastectomy itself.

This seemed incorrect, and Ron resolved that this decision would not stand.

Ron Lieber: These entities will not prevail. I will emerge victorious, given my professional standing.

Dan: He is an established expert in overcoming system-imposed obstacles.

Ron Lieber: I am committed to advocating for my wife.

Dan: And he was not facing this challenge in isolation.

Ron Lieber: I am employed by a reputable organization with an exceptional human resources department.

Dan: He also anticipated that the hospital would provide support in this endeavor.

Ron Lieber: My assumption is that Memorial Sloan Kettering employs a team of approximately 10 to 20 individuals dedicated solely to managing administrative complications. Therefore, a resolution is inevitable.

Dan: One principle he was determined to uphold throughout this process was to refrain from leveraging his affiliation with The New York Times to seek preferential treatment from the hospital or the insurance company.

Ron Lieber: We adhere to arguably the most stringent ethical code globally. Any exertion of undue influence would result in immediate termination. The moment one identifies themselves to 1-800 United Healthcare as an employee of The New York Times and requests special consideration, their employment is jeopardized. There are no second chances.

Dan: He did, however, intend to meticulously document all proceedings. The experience, he perceived, held the potential to become a compelling narrative.

And I can confirm at this moment that it did. Ron eventually published his family’s account in The New York Times, aiming to assist others in avoiding the disconcerting experience of receiving a distressing insurance problem notification with insufficient time to address it.

Hundreds of readers responded with personal anecdotes, suggestions, and expressions of dissatisfaction.

In response, Ron revisited the subject, introducing a tool he hoped would empower patients—and crucially, their physicians—to prevent such alarming situations, at least in some instances.

I find this approach exceptionally commendable.

This program, “An Arm and a Leg,” delves into the reasons behind the exorbitant cost of healthcare and potential solutions. I am Dan Weissmann, a journalist who embraces challenges. Our objective on this show is to transform one of the most anxiety-inducing, infuriating, and disheartening aspects of American life into content that is both engaging, empowering, and practical.

Jodi returned from her trip with friends on Sunday. Her surgery was scheduled for the following morning. Ron informed her of the insurance denial, and she reacted with significant distress.

Ron Lieber: Her reaction was not one of anger, but rather sadness and stress, emotions that are entirely inappropriate under such circumstances, especially when preparing for major surgery.

Dan: Concurrently, Ron endeavored to resolve the insurance issue. However, on a Sunday, his options were considerably limited.

Ron Lieber: There was a rather cumbersome appeal form that could be submitted via a designated emergency fax line. Consequently, I downloaded an e-fax application for the first time in 19 years and transmitted the document into the void. No response was received.

Dan: The subsequent morning, upon their arrival for the surgery, Ron, anticipating approximately six to eight hours of unoccupied time while Jodi was under anesthesia, began to explore the hospital premises, seeking an individual who could elucidate the situation and advise on the necessary course of action.

Ron Lieber: I approached various administrative desks, presenting them with the communication I had received from UnitedHealthcare.

Dan: The personnel at these desks expressed surprise, noting that they had received a similar notice that very day.

The unfolding narrative of Ron and Jodi’s predicament coincided with a more significant news event that had commenced just a few days prior.

Jessica Tisch: In Midtown Manhattan, earlier today, Brian Thompson, the 50-year-old CEO of UnitedHealthcare, was fatally shot in what preliminary investigation suggests was a bold, premeditated act.

News announcer: United Healthcare has been the target of protests, reportedly denying one in every three claims submitted.

News reporter: CBS News has also confirmed that law enforcement discovered shell casings at the crime scene bearing the inscribed words: deny, defend, and depose.

Dan: These specific inscriptions—”deny, defend, depose”—led many to infer that issues such as prior authorization played a role in the perpetrator’s motivations.

Furthermore, authorities were actively pursuing the suspected assailant, subsequently identified as Luigi Mangione, on that very morning. Therefore, when Ron presented his UnitedHealthcare denial at the billing office…

Ron Lieber: Individuals inquired, “Is he still at large?” They were astonished that the very issue that had apparently instigated Luigi’s distress was manifesting in real time while the manhunt was ongoing.

Dan: They also swiftly provided Ron with reassurance regarding his immediate situation.

Ron Lieber: The amiable receptionist at the billing department efficiently accessed the information on her computer and stated, “Oh yes. She indicated that this would not pose an obstacle, although it might take some time. You need not be concerned.”

Dan: And she imparted a piece of information that sparked further contemplation for Ron.

Ron Lieber: She remarked, “We received notification regarding this approximately seven to eight days ago. Had we anticipated any complications, we would have promptly contacted you to advise you not to proceed.”

Dan: Ron’s reaction was: “I sincerely wish you had provided us with advance notice and this assurance sooner.”

Ron Lieber: I am displeased because we were only apprised of the situation 36 hours prior to the scheduled procedure, rendering it too late to take any remedial action, as it was a Saturday evening and the surgery was set for Monday morning. Why was this information not conveyed to us immediately?

Dan: And he began to consider his subsequent course of action.

Ron Lieber: Concurrently, at least three distinct internal dialogues were occurring. Firstly, I was confronting a personal situation that required resolution with minimal financial outlay. Secondly, I recognized this as a potential news story and felt compelled to meticulously document all details, not only for my own benefit but also to ensure accurate record-keeping and to enable me to present the most compelling case to readers and the involved entities when the time came to seek explanations. Thirdly, I aimed to avoid any action that could jeopardize the narrative’s integrity. This entailed maintaining composure, exercising patience, and assiduously avoiding any mention of my affiliation with The New York Times…

Dan: How does one maintain their cover?

Ron Lieber: Precisely. Correct.

Dan: Furthermore, another consideration emerged: UnitedHealthcare was the dominant news item of the day, with reports indicating that pre-authorization issues were among the alleged killer’s primary grievances.

Ron Lieber: Subsequently, I engaged in a discussion with my editors while Jodi was still under anesthesia, proposing that I wished to report on this matter immediately. This transpired approximately an hour before Luigi’s apprehension, placing us at the epicenter of the news. I believed this was the catalyst for his actions and that we should proceed with the story. My editor, with sound judgment, advised against it. To ensure the article’s utility for the readership and absolute adherence to our ethical obligations, it was imperative to allow the situation to unfold to its natural conclusion.

Dan: Ron redirected his attention to the immediate priorities, which did not include pursuing a journalistic scoop.

Ron Lieber: I was not the central figure in this narrative. My wife was the protagonist; she was unwell, and our primary focus was her recovery. This was a significant undertaking, and I was, in fact, relieved when my editor advised a temporary halt to the reporting process around two in the afternoon.

Dan: Further relief was forthcoming shortly thereafter.

Ron Lieber: Jodi’s surgery was highly successful, and the surgical team performed exceptionally. Both the surgeons and we were very pleased. Her recovery proceeded without incident, and we felt a profound sense of well-being. Consequently, I began to monitor the mail, anticipating a substantial hospital bill or communication from United Healthcare. Weeks elapsed without any correspondence.

Ron engaged in a course of action that I would not typically expect or recommend for an ordinary individual: he continued to wait. This was partly due to his strong conviction that the situation would resolve favorably and, as a reporter, he was gathering data on how the system functioned when left to its own devices.

Finally, on March 1st—more than two and a half months after Jodi’s surgery—Ron contacted United Healthcare. He stated, “You informed us in early December that you were denying coverage, and I submitted an appeal via fax. I am inquiring if there has been any progress on this matter.”

Ron Lieber: Upon reviewing the file, they responded, “Oh yes. The appeal was forwarded to the attending physician for review today.” I then asked, “You waited approximately two and a half months to take this action?” To which they replied, “Yes.” I acknowledged this.

Dan: After concluding the call, Ron waited an additional few weeks before contacting them again. A United Healthcare representative then confirmed that the matter appeared to be resolved.

Subsequently, Ron received a bill that was reasonable in amount, which he promptly paid. This marked the transition back to his role as a reporter.

Thus, Ron the Reporter could now pose the same questions that Ron the Private Citizen had been asking all along.

Was it not feasible for them to provide him and Jodi with advance notification?

Ron: Why did you not inform us immediately, rather than through the United States Postal Service, which some individuals disregard entirely or may not even receive? Why did you not issue some form of alert? Send us a text message. Call us on her phone. Send an email. Perhaps initiate all three methods. Or even fly a banner over Prospect Park declaring: ‘Ron and Jodi, contact UnitedHealthcare immediately. You have a problem.’

Dan: There exists a vast array of critical questions concerning the prior authorization process itself—for instance, why would a mastectomy for breast cancer ever be denied?

However, for the purpose of this narrative, Ron maintained a focused approach.

Ron Lieber: The discussion I aim to have with UnitedHealthcare is not accusatory, suggesting their inadequacy or the system’s inherent flaws. My sole inquiry is: given that we must currently operate within this system, why did you not notify us?

Dan: The initial phrase of this question—GIVEN THAT WE HAVE TO LIVE WITHIN THIS SYSTEM FOR NOW—resonated profoundly with me because, regrettably, we do.

And it is indeed a remarkably reasonable question: Is providing individuals with advance notice not the absolute minimum expected? Ron posed this question, officially.

Ron Lieber: And this was their response: They stated, “Yes, we acknowledge that further improvements are necessary regarding prior authorization, with considerable deliberation on the matter.” Subsequently, they added: ‘We are continuously implementing internal modifications to assist members in navigating these types of situations, which includes offering opt-in paperless communication channels.’

Dan: Opt-in. Implied meaning: “Oh, well, you had the option to opt in.” Ron’s reaction was one of exasperation: “Are you suggesting this is my fault because I failed to opt in?” He recounts continuing to argue with the United Healthcare spokesperson, whom he describes as a thoroughly courteous individual, emphasizing the imperative of providing advance notification to individuals. His arguments, however, were unavailing.

Ron Lieber: Consequently, I concluded that United Healthcare demonstrated little enthusiasm for fundamentally altering their procedures to align with my recommendations.

Dan: And by the way, Ron offers a hypothesis as to why they might be reluctant.

Ron Lieber: Implementing the type of notification system I propose would necessitate a significant expansion of their customer service staff, incurring substantial operational costs. Their objective is, in fact, to minimize direct inquiries regarding these matters. However, I subsequently conceived of an alternative strategy to circumvent their reluctance.

Dan: This alternative strategy will be discussed shortly.

This installment of An Arm and a Leg is a collaborative production between Public Road Productions and KFF Health News. KFF Health News is a journalistic entity dedicated to covering health-related issues across the United States, with its journalists consistently receiving numerous accolades. We are honored by this collaboration.

Ron has devised another strategy for addressing the reality of operating within a system where insurance companies issue perplexing and distressing denials of care to millions, ensuring that individuals are not blindsided by such news at the eleventh hour.

This strategy involves potentially engaging our HEALTHCARE PROVIDERS. After all, they have a vested interest in treating patients and ensuring timely payment. We represent a natural alliance.

Thus, a pertinent question arose for the personnel at Memorial Sloan Kettering, a question he had refrained from pursuing on the day of Jodi’s surgery.

It was at this juncture that the billing department representative informed him that they had been aware of United’s denial for seven to eight days. He inquired why they had not provided him with advance notification.

Ron Lieber: Their response was essentially: We prefer not to inconvenience patients with such matters. We limit communication to what we term clinically essential information. However, my counterargument is this: Prior to surgery, a patient’s mental well-being should be a paramount concern for the institution. It is crucial for individuals to approach surgery with mental clarity, free from undue anxiety or apprehension.

Dan: And once again, Ron did not succeed in persuading Memorial Sloan Kettering to revise their policy.

Consequently, when he documented these events in a published column in August—over eight months after Jodi’s surgery—he offered readers a couple of recommendations.

First: Yes, if your insurance provider mandates opting in for advance notifications, then proceed and opt in.

Second: If you require a specific medical treatment, engage with your physician’s office by posing several questions: Is prior authorization a factor in this instance? Can the request for authorization be initiated as early as possible to circumvent any last-minute complications? Should any impediments arise, can you ensure I receive prompt notification? And if I uncover an issue, whom within your office should I contact?

That particular column garnered significant attention, eliciting over 500 comments—an exceptionally high volume, even for The New York Times. Many expressed support, while numerous others shared accounts of experiences far more severe than those of Jodi and Ron.

Ron Lieber: Several individuals reported being sent home on the morning of their scheduled surgery due to unresolved insurance issues. One patient, who had already received the anesthetic injection, had it withdrawn, and was required to reschedule their procedure for a later date.

Dan: Oh my God.

Ron Lieber: Additionally, a small contingent of readers criticized my approach, asserting that I should have thoroughly investigated the potential for an insurance denial in advance.

Dan: He contemplated offering this advice in a subsequent article: “Never let your guard down. Make multiple inquiries.”

However, he opted for a different strategy.

Ron Lieber: I then considered how our situation might have been averted. It occurred to me that a concise, straightforward document provided at the time of diagnosis or surgery scheduling could have served as a crucial heads-up.

Dan: Such a document could have alerted them to the possibility of such occurrences. In his newsletter, he solicited suggestions from readers regarding the content of this informational document.

He reported receiving numerous responses, including some from irate physicians.

Ron Lieber: They expressed, “Who are you to dictate how I manage my medical practice?” And the most vocal sentiment was, “This is not my responsibility. Why are you placing this burden on me?” Conversely, an equal number of physicians responded, requesting that I forward the information to them upon its release, in case they missed the initial publication.

Dan: And he received a wealth of constructive recommendations. He subsequently published an article featuring a template for a notice that physicians could utilize.

Ron Lieber: The notice stated: ‘Hello, this document explains prior authorization and its operational procedures. Occasionally, individuals encounter issues where the insurance provider denies coverage. We aim to alleviate your concerns regarding this matter. You are welcome to contact us at this number or email address if you encounter any difficulties, and we will endeavor to resolve them. Should you have any questions concerning this form, please consult our billing specialist. We understand you may not wish to allocate valuable appointment time to discuss this with your physician, just as they may prefer not to, but we want to ensure you are apprised of this information in advance.’

Dan: Once again, a multitude of responses were received, many of which were highly beneficial.

Ron Lieber: I received exceptionally insightful critical feedback, leading me to realize that the notice could be significantly improved.

Dan: For instance, Ron’s initial draft included some commentary from a physician’s perspective regarding insurance companies. For example:

“It is often necessary for a physician to engage in a peer review with an insurance company representative. We find this process to be burdensome, as the ‘peer’ on the call may not possess the same level of expertise as we do. This prolongs the interaction, increases our operational expenses, and detracts from the time we can dedicate to patient care.”

While many physicians voice such sentiments in various contexts, they typically refrain from doing so on official hospital letterhead.

Ron Lieber: A number of physicians indicated that their legal departments would likely not approve such communication. They expressed a desire to comply but stated it was not feasible within their organizational structure. To this, I responded by suggesting they forward the document to their legal counsel and engage in a discussion with me to determine acceptable parameters.

Dan: Other readers advised Ron to simplify the language. They utilized software to analyze the readability of his text.

Ron Lieber: They then provided feedback, stating that the text was written at a twelfth-grade reading level and that their patients, some of whom were non-native English speakers, would struggle to comprehend it. They recommended revising it to a fifth-grade reading level. I acknowledged that this was sound advice.

Dan: Ron meticulously processed all the feedback he received regarding the memo he had published.

Ron Lieber: Consequently, I released a revised version that was superior—more concise, employing simpler language, and omitting the extraneous commentary.

Dan: A link to this second iteration will be provided wherever you are accessing this broadcast. Healthcare professionals, or those who know such individuals who might find it beneficial, are encouraged to review and disseminate it.

Among the numerous comments on Ron’s articles, one particular reader’s wish, expressed as a lament, resonated with me. This individual conveyed that anyone requiring major medical care should ideally be enrolled in a specialized training program to effectively navigate the healthcare system.

Ron Lieber: This is precisely the reason I am employed, Dan, and I am confident it is also why you hold your position. While I would welcome the obsolescence of my profession, the manner in which this would occur is through the mandatory implementation of certificate programs across 25 distinct categories of personal finance. This is how my professional role would become redundant. However, as such mandatory certifications are highly improbable in any of the personal finance domains that we are compelled to navigate as human beings, my role persists, and I endeavor to execute it with increasing proficiency.

Dan: I concur. While there are numerous aspects of my profession that I find rewarding, I lament the necessity for it. Countless individuals face circumstances far more challenging than those encountered by Ron Lieber and Jodi Kantor.

In her forthcoming book, “Coverage Denied,” scheduled for publication this spring, Miranda Yaver, a professor at the University of Pittsburgh, cites estimates of annual claim denials ranging from 850 million to 3 billion.

She also presents data indicating that appeals are successful more often than is commonly believed, with a success rate of approximately fifty percent.

However, the appeals process is arduous. Individuals with fewer advantages, such as those lacking the flexibility of schedule required for consistent phone calls and faxes, face greater difficulties.

She characterizes the outcome of this disparity as “Rationing by inconvenience.”

And all of us can benefit from any assistance that can make life less frustrating and inconvenient. Therefore, I will conclude with Ron Lieber’s response to my final, pivotal question for him.

Because hearing a portion of his advice on how to avoid being blindsided by an insurance denial prompted another query, one that seemed appropriate to direct to an expert in navigating complex systems.

I posed the question: “You recommend opting in for email and text notifications from your insurance provider to potentially receive quicker alerts. Suppose I follow this advice. How am I expected to locate these messages within my inbox, which becomes increasingly challenging to manage daily with extraneous content I neither want nor need to review?”

I asked him: “How do you, Ron Lieber, manage your incoming communications? How do you identify what genuinely requires your attention?”

And he provided a well-reasoned answer:

Ron Lieber: Yes. So, I maintain three distinct email inboxes. I have my professional work email, a personal email solely for personal correspondence and essential matters such as children’s school communications and college tuition payments. And then I utilize an older Yahoo email account for all other miscellaneous communications. Consequently, I typically review the accumulated emails in the Yahoo inbox for the preceding 12 to 24 hours approximately once per day. Furthermore, roughly once a month, I dedicate time to clearing the inbox by unsubscribing from at least 10 unwanted subscriptions. This approach helps maintain a manageable volume.

Dan: This is exceptionally valuable counsel. I have not yet had the opportunity to implement it since our conversation with Ron—primarily due to my current deadline for this episode—but I assure you, I intend to.

Here is another action I plan to take in the coming weeks: I myself will be undergoing surgery. It is a hernia repair procedure, which I anticipate will proceed smoothly under expert care. However, it is scheduled to occur a few days prior to the planned release of our subsequent episode.

Therefore, by chance, I have a compelling story from another individual to share with you then. We will present another new episode for your consideration upon my return.

In the interim, we will continue to distribute the First Aid Kit newsletter. If you are not yet subscribed, I highly recommend it!

My colleagues, Emily and Claire, have been delivering essential information, such as details about what is typically covered during your annual physical examination. Many believe it is more comprehensive than it actually is.

This reality is unfortunate but critically important to be aware of. If you have not yet subscribed, please visit arm and a leg show dot com, slash, newsletter.

I will reconnect with you shortly. Until then, please take good care of yourself.

This episode of An Arm and a Leg was produced by myself, Dan Weissmann, with assistance from Emily Pisacreta, and edited by Ellen Weiss.

Adam Raymonda serves as our audio specialist.

Our musical score is courtesy of Dave Weiner and Blue Dot Sessions.

Claire Davenport is our engagement producer.

Sarah Ballema holds the position of Operations Manager. Bea Bosco is our consulting director of operations.

An Arm and a Leg is a collaborative effort with KFF Health News, a national newsroom dedicated to producing in-depth reporting on health-related issues in the United States and a key component of KFF, an independent organization providing research, polling, and journalism in the field of health policy.

Zach Dyer is the senior audio producer at KFF Health News and serves as the editorial liaison for this program.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR affiliate news station.

We extend our gratitude to the Institute for Nonprofit News for acting as our fiscal sponsor.

This arrangement enables us to accept tax-deductible donations. Further information about INN can be found at INN.org.

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