“Not medically necessary.”
Says who…a doctor?
No…an insurance company.
And the insurance company here isn’t just any insurance company: we’re talking about UnitedHealthcare, the largest insurance company in the country.
A company who made $360 billion in profits last year – we’ll pause so you can read that sentence again – in part through strategies to block care and preserve profits.
Such is the case for one college student at Penn State.
Christopher McNaughton’s story shows just how many loopholes, workarounds, and downright deceptive strategies big insurance companies use not to cover your care.
According to ProPublica, insurers reject around 1 in every 7 claims. “Many people, faced with fighting insurance companies, simply give up: One study found that Americans file formal appeals on only 0.1% of claims denied by insurers under the Affordable Care Act.”
McNaughton has a severe case of ulcerative colitis, a chronic condition that requires ongoing doctor visits and medication. Like most chronic conditions, it can be expensive. But that’s the point of having medical insurance, right? So, when UnitedHealthcare (United) refused to cover the drugs that were finally helping McNaughton’s condition—drugs prescribed by a Mayo Clinic doctor, might we add—McNaughton and his family fought back.
But fighting back wasn’t easy, starting with a lawsuit. The suit uncovered internal emails and tape-recorded conversations between United employees, the latter being the most damning evidence against the insurer.
“Those records offer an extraordinary behind-the-scenes look at how one of America’s leading health care insurers relentlessly fought to reduce spending on care, even as its profits rose to record levels,” notes ProPublica.
The lawsuit also alleged other sketchy actions by United, including misrepresenting critical findings, ignoring warnings from doctors about altering McNaughton’s drug plan, burying another doctor’s report, and inaccurately reporting to Penn State and the family that McNaughton’s doctor had agreed to lower his medication dosage.
One of the biggest reasons for United’s denial was that McNaughton was prescribed doses of his medication that far exceeded FDA guidelines. And while the insurer claimed these doses gave them pause “to ensure patient safety,” in reality, McNaughton had tried a combination of drugs at different doses with little to no success. What ended up working for him exceeded FDA guidelines, but this is a common practice known as off-label prescribing. This is when physicians use their judgement to prescribe more, less or a different medication than standard guidelines recommend. Why? Because everybody is different, and guidelines aren’t guaranteed effective for every single person. For example, an estimated 1 in 5 prescriptions are written for off-label uses, per the Agency for Healthcare Research and Quality.
And when United recommended lowering the dosage, McNaughton’s doctor even said that altering his treatment “would have serious detrimental effects on both his short term and long-term health and could potentially involve life threatening complications,” according to the article.
Apparently, this didn’t matter to United.
Per ProPublica, officials calculated in emails “what McNaughton was costing to keep his crippling disease at bay” and the savings potential of a cheaper treatment—one that already failed him.
We can’t say we’re surprised that this is how United behaved. Many insurers hide behind the curtain of “medical necessity” in order to deny your care. But the fact of the matter is, doctors—not insurers—should get to decide what kind of healthcare services you need. That’s what they went to medical school for, and that’s why patients seek their care. Insurance companies, on the other hand, have bottom lines to meet, and want to simplify your care to a list of binary options: emergency vs. non-emergency, covered vs. not covered, medically necessary vs. medically unnecessary.
The truth is, cases like McNaughton’s aren’t black-and-white, and sadly, they’re not uncommon.