Every year, Americans pay more for health insurance premiums, only to face a brutal reality when they need care: denied claims, stalled approvals, and decisions about their health made by people who aren't even clinicians. Behind the curtain of our complex health care system lies a deeply flawed process that prioritizes cost containment over patient outcomes -- a process that needs to change.
Recent headlines have been dominated by the tragic killing of a UnitedHealth Group CEO, an event that underscores the heightened tensions surrounding our health care system. While the incident may not be directly tied to insurance policies, it serves as a chilling reminder of the deep frustrations and inequalities that define American health care today. The stakes couldn't be higher -- this system, driven by algorithms and profit margins, increasingly feels like it's stacked against patients and providers alike.
The claim submission maze
When you visit your doctor, a seemingly simple process begins: your provider submits a claim to your insurance company for the services rendered. What happens next is anything but simple.
Claims are evaluated for "appropriateness" by insurance companies. What defines "appropriate" often boils down to specific words, codes or phrases. If a provider misses a single detail -- be it a diagnostic code or a key phrase -- the claim can be denied. Conversely, if too much information is submitted, the claim can also be rejected. These rules force providers to navigate a minefield of bureaucracy, often at the expense of patient care.
To complicate matters, providers must submit claims within a strict "timely filing" window -- often as short as 30 to 90 days. If the deadline is missed, insurers are off the hook, and the provider or patient is left footing the bill. This system incentivizes insurers to reject claims outright, hoping providers won't have the time or resources to fight back.
When providers do have the resources to appeal denied claims, the process often feels like a deliberate obstacle course. The process may require resubmitting documents, addressing new denials based on technicalities, or waiting weeks for responses to even simple inquiries. These delays are not accidental -- they are systemic. For many providers, particularly small practices, the resources required to fight back aren't available. The result? The claim dies, and the cost is passed on to you, the patient.
Who's really deciding what's medically necessary?
Perhaps the most infuriating aspect of this process is who decides whether a treatment is "medically necessary."
While patients and providers assume these decisions are made by medical professionals, claims are often reviewed by outsourced workers overseas. While outsourcing itself isn't inherently problematic, a 2022 investigation by ProPublica revealed that many reviewers are required to follow rigid algorithms and scripts rather than exercising judgment. This means your mother's chemotherapy or your child's surgery could be denied -- against the advice and recommendation of your doctor -- by someone who has never set foot in a medical school.
The subjective nature of reimbursement rates
Beyond denied claims, the system of negotiating reimbursement rates further exposes the inequities of American health care. Every provider must credential with insurance companies and agree to a rate for their services. These rates are often benchmarked against Medicare's reimbursement rate. For example, a provider might negotiate a rate of 120% of Medicare, meaning they earn 20% more than Medicare would pay.
But this process is far from transparent or fair. Two clinics in the same building, seeing the same types of patients, can negotiate vastly different rates. One might secure 150% of Medicare while the other settles for 90%. Why? Negotiations depend on the leverage of the provider and, sometimes, sheer luck -- like catching an insurance rep in a good mood.
A glimpse overseas: Is national health care the answer?
While it's tempting to look at other countries' health care systems as a solution, they come with their own challenges. A 2023 report by the British Medical Association highlighted record-breaking wait times for patients of the UK's National Health Service (NHS), with over 7 million patients in England awaiting treatment as of mid-2023. The NHS also grapples with workforce shortages and underfunding, leading to rationed care.
These examples show that while national health care systems address some issues, they introduce others, particularly when clinical outcomes are dictated by political considerations and budgetary constraints rather than medical necessity.
Clinical outcomes and financial management
At the heart of the issue lies a dangerous overlap between clinical outcomes and financial management. When insurers prioritize cutting costs over patient care, lives are put at risk. Take the tragic case of a California woman whose breast cancer treatment was delayed due to claim denials for "medical necessity." By the time her appeal was approved, her cancer had progressed, leaving her with fewer treatment options and a diminished prognosis.
These decisions shouldn't be made by algorithms or untrained workers following a script. Health care is too nuanced, too human, to be reduced to spreadsheets and dollar signs.
The call to action
This isn't a call for a complete overhaul or for adopting another country's system wholesale. It's a call to re-center health care around the people it's meant to serve. As chief financial officer of a health care organization, I've seen how this broken system affects patients and providers. Patients deserve care guided by their doctors, not by untrained workers or profit-driven algorithms.
One of the most troubling aspects of our health care system is the glaring conflict of interest among policymakers who hold significant investments in the very health care organizations they regulate. A 2021 New York Times investigation revealed that dozens of lawmakers had financial stakes in companies like UnitedHealth Group and Anthem, reaping personal profits from rising stock prices fueled by denial-driven profitability. When those tasked with crafting health care legislation stand to benefit from maintaining the status quo, it raises serious ethical questions about whose interests are truly being served -- the patients or the profits?
Because in the Venn diagram of health care, clinical outcomes and financial management should never intersect. It's time for us to reclaim health care from the algorithms and profit margins -- and put it where it belongs: in the hands of the professionals who know how to heal.
This is of course easier said than done. But acknowledging the problem is the first step. Policymakers must hold insurers accountable for their practices. Patients must demand transparency about who's reviewing their claims and why. And providers must advocate for fair reimbursement rates that reflect the true cost of delivering care.
We must start somewhere. Because no one should die waiting for a claim to be approved or denied by someone who knows nothing about medicine.
There is one clear step we can take: put health care decisions back in the hands of trained professionals.
Katie Acosta is a health care executive with over two decades of leadership experience in finance and operations. She lives in Las Vegas and has a lifelong passion for making a positive impact in the health care industry.