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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. We're going to talk now about something that health insurance doesn't do more often than it used to not do it. I think that's English. It's an experience that's becoming more and more common at the pharmacy counter. According to a new report in The New York Times, private health insurers are denying claims for prescription drugs at a higher rate now than they were a decade ago.

Maybe you saw the story that came out a few days ago, and joining us with insights from her reporting is Sarah Kliff, Investigative Health Care Reporter for The New York Times. Hi, Sarah, welcome back to WNYC.

Sarah Kliff: Yes, thanks for having me.

Brian Lehrer: For people who missed your article, and we'll open up the phones for people's personal experiences to help you report the story further, but can you give us a quick recap of the big takeaways?

Sarah Kliff: Sure, and I'm sure we'll get plenty of experiences, because this is a pretty common experience in our health care system. The big takeaway, is we've worked with a large health data company, Komodo Health, to analyze about four billion health insurance claims from private insurers over the past decade, which is often a black box, and what we saw was pretty startling.

We saw a jump in denials by private insurers of 25% between 2016 and 2023. One thing I do want to say from the outset, is some of these denials get resolved. Not all of these claims mean someone doesn't go home with their prescription, but they do indicate there is this growing friction in our health care system between a drug getting prescribed by a doctor, and a patient receiving that drug.

Brian Lehrer: Certain drugs, certain classifications of drugs?

Sarah Kliff: Yes, there's a few. It was a little difficult to get that granular. One category that came up a lot were inhalers used to treat asthma. Those are ones that seem to be seeing a decently big increase in denials. Another one is weight loss drugs. Ozempic is a new one that insurers are dealing with. A lot of insurance companies don't cover that yet, so those are two classes of drugs that might be in the mix here.

Brian Lehrer: The inhalers really shocks me. I know, we've probably all known kids, or even adults who have to use inhalers as emergency relief for asthma, or related conditions. How could they deny that?

Sarah Kliff: Yes. A lot of it has to do with substituting in that case, where they're going to ask you to switch to a different inhaler. Sometimes that might be fine. Sometimes it might work well to control your asthma, but other people I talked to for this story including someone who's trying to get their asthma inhaler in Los Angeles during the wildfires, they had one inhaler that worked for them, and their insurance company wouldn't cover it, and that caused a big issue, so a lot of the story there is insurance companies trying to substitute people to cheaper medications, sometimes it's fine, and sometimes it is less fine.

Brian Lehrer: All right, listeners, help us report this story. Help Sarah Kliff, Investigative Health Care Reporter for The New York Times, report her story. Has your insurance recently refused to cover any prescription drugs that you needed? Has anyone's insurance suddenly denied coverage for a drug that it had covered before? 212-433-WNYC, 212-433-9692. How has this affected you? Anyone listening now have to go without a medication, because your insurance wouldn't cover it?

Any doctors listening, pharmacists listening who want to weigh in on this? Doctors, what do you do when something that you think your patient needed gets denied by the health insurer, and they can't afford to get it out of pocket? What do you do? Give us an example. Having to do with a particular kind of condition, and a particular drug. 212-433-WNYC, 212-433-9692. With the caveat that it's difficult to know for sure, you propose in your article a few explanations for why insurers are denying coverage for prescription drugs more often now. Can you give us some of those?

Sarah Kliff: Yes. Again, this is a bit of an opaque area that we're still trying to understand. One of them is just the rising cost of drugs. It gets more and more expensive every year. With prices going up, insurance companies are looking for ways to tamp down on those costs to keep premiums affordable for patients, so there's always this trade off. The more insurance companies cover, the more premiums rise, so they're trying to strike that balance.

Another thing I thought was a little bit interesting was the role of Ozempic, this big blockbuster drug that seems to be very powerful, and very successful. One idea put to me by experts who study this, is maybe it's not just insurers not always covering Ozempic, but they're tightening up other parts of their drug prescription rules to make space for the costs.

They're limiting the refills for example, saying, "Okay, you have to wait 30 days to get this," and when you could have refilled earlier. In other instances, another factor that was brought to my attention was AI. A likelihood of AI being used more in claim processing, just like it's being used more in anything, in everything we do right now that, that could also be playing a role here.

Brian Lehrer: AI using a lot of data to say, "Oh, this person doesn't need this drug," based on trends having to do with what AI sees in big data sets?

Sarah Kliff: Yes, exactly. Maybe if anyone's played around with AI, sometimes you see, it does a little bit of hallucinating here and there, that maybe sometimes it's not quite getting the outcome right, and that it still needs a bit of fine tuning.

Brian Lehrer: Maybe we need to prescribe anti-hallucinogens for artificial intelligence.

Sarah Kliff: [laughs]

Brian Lehrer: Joyce in Highland Park, you're on WNYC. Hi, Joyce.

Joyce: Hi. Thank you so much for taking my call. The reason I called, is because I had this experience that you're talking about. Last year, I went to get my Advair. I'm 67, I'm immunocompromised, and Advair has worked very well for me, and they told me suddenly, it wasn't covered, and that I wasn't even covered to get the generic, so I called my insurance company, they confirmed that I couldn't even get the generic. They wanted me to take a different medicine.

Then, they told me that I could get the medicine that helps me, if the other one didn't work for me, so then I said, "You're basically telling me, 67, immunocompromised, that I have to get sick on the other medicine that's cheaper that you want to give me before you'll give me the one that works?" Then, I got off the phone, I called my Congressman with the same thing.

I called back, I got another person, said the same thing, and they finally agreed to give me the generic. The reason I called was so that I would let people know that, you can push back. It does require a lot of talking and a lot of calling.

Brian Lehrer: I think you've got a tip here for people, which is that, if you follow up, if you have the fortitude and the time to follow up, you can get some of these things reversed. Would you say, Joyce, that's the moral of your story?

Joyce: Yes, that's the moral of my story, and we have to do that. We have to all push back.

Brian Lehrer: Thank you very much. That's the other part of what I think this segment is about, Sarah, when people face these denials that they think are unfair, or they just think they really need the medication, and so does their doctor. What can you do?

Sarah Kliff: Yes, I mean exactly what Joyce described, you can push back. I think she made the smart move of reaching out to a legislator on this issue. It is unfortunate though how much work it requires of patients, often quite sick patients. The whole reason they're doing this work is to get needed prescriptions, so you definitely can. Every insurance plan has an appeals process. You can go to that appeals process.

Every state has an insurance regulator. If you feel like they are not following the letter of your policy, you can file a complaint with your state insurance regulator. The data we do have suggests that appeals are often quite successful, but very few people think to file them, so that is probably the first step I'd recommend if you think of something has been improperly denied, is to go through the appeals process.

Unfortunately, it can be time consuming. It sounds like in Joyce's experience was definitely-- Shows that that it might require multiple phone calls. It can be a frustrating experience to eventually get to coverage.

Brian Lehrer: Do you have any stats on how often appeals of denials are successful? Because I'm sure we all read that paperwork, and think, "Oh, right.

Sarah Kliff: Exactly. [chuckles]

Brian Lehrer: I'm going to write back to them, and say, 'You were wrong,' and they're going to say, 'Okay, we're going to cover this now.'"

Sarah Kliff: They are surprisingly successful. The data we have, we don't have data on the big employer sponsored plans that most of us have. That information is just not public. The one place we do have maybe similar data is from Obamacare plans, the individual plans people buy on HealthCare.gov, and there the Kaiser Family Foundation has just done a research. They found that about half of denials get overturned, but only 1% of denied claims are ever appealed in the first place, so pretty good odds if you file one, but most people are not, because of the reasons you said, Brian. It looks big, it's intimidating. A lot of people do not file those appeals.

Brian Lehrer: All right, so there's a good tip. File those appeals. Listener writes, this is so sad, "I've been using albuterol," that's an inhaler for asthma and things like that. "I've been using albuterol my entire life. Recently, my insurance stopped covering it, and the generics propellant is inadequate, and the copay has gone from $20 to $45. It's getting expensive to breathe these days." Writes that listener. Annie in Westchester. You're on WNYC. Hi, Annie.

Annie: Hi. Hi, thanks for taking my call. I went on Ozempic about two years ago, and I did a great job losing weight, and suddenly, of course, my insurance stopped covering it. I mean, really very quickly into the process, and my doc-- Not only that, they didn't want to cover my visits to my doctor for my body composition analysis, whether I have enough muscle mass and things like that, because that's a danger with this drug.

My doctor decided, okay, let's move to the compounding pharmacy, so we got the compounding, and then, suddenly, they got wind of that, and they don't want to cover that anymore, so my cholesterol went down, my blood pressure went down. I didn't want to look like a Vogue model. I just wanted to look healthy, and I do. Now, I'm paying out of pocket to look healthy, and to feel healthy, and to be healthy, and it is ridiculous. They acted like it's a moral failure on my part that a postmenopausal woman can't keep her weight down, so I will take my answer off the air. [chuckles]

Brian Lehrer: Annie, thank you very much, and I'm sorry for your travails on this. Do you hear a lot of stories like that, Sarah?

Sarah Kliff: Yes, absolutely. I hear a lot of stories like that. I think Ozempic is an area where the coverage is very in flux, and I think that's really difficult for patients. We're not talking about something you take once or twice. We're talking about Ozempic, essentially, being a maintenance medication that Annie was describing, can have some really wonderful health effects, and then to have that disruption come out of nowhere, is quite difficult to navigate. I think we're only going to be hearing more stories like this as drugs like that become part of our health system. They're rapidly becoming pretty decent line item in our health system.

Brian Lehrer: What about the story that the caller told, the way she told it? Because I think an insurer might hear that and say from their perspective, and obviously, with their profit motive, "You're doing this to look better and feel better. That's not necessarily a medical need."

Sarah Kliff: Sure. Yes, but I think the caller was also talking about how her cholesterol was going down, so I think the two are definitely intertwined. One point I would make is, often the decision about what to cover, it's not being made by the insurance plan. You have all these actors in the system. One big one are employers. It's often your employer who's deciding, "Okay, here are the benefits I'm willing to cover. We're going to cover Ozempic. We're not going to cover Ozempic," is often the decision made by the employer sponsoring the plan.

There's also a big role of these pharmacy benefit managers which have been getting a lot more attention lately. They're third party companies that insurance contract out to manage the drug side of their benefit, so the decision point even if the insurer is the one the denial comes from, the decision point could be from a lot of different actors in this space.

Brian Lehrer: Right. Can you talk more about the prescription management, the prescription benefit managers, these PBMs, right?

Sarah Kliff: [chuckles] PBM, yes.

Brian Lehrer: This is a relatively new layer in fairly recent years of bureaucracy between your doctor and your medication.

Sarah Kliff: Yes. The idea of these was that, the drug side of an insurance benefit, it's tricky and difficult, so insurance companies started contracting with these PBM pharmacy benefit managers, who said they would do just that, that they would take care of making good formulary, finding the drugs your folks need, and negotiating good discounts. What reporting from some of my colleagues at The Times has revealed, is that often they are not giving the best deals to patients, that they are not passing along the savings that they are negotiating in their contracts, and that they are playing a role in driving up the cost of medications for folks.

It's just, I think each layer of actor you add in health care, it just makes it all the more difficult for the patient to get to the bottom of, "Why is this being denied? Who do I need to call?" Having all those layers between you and a claim getting processed, just makes this whole experience much more opaque.

Brian Lehrer: Sarah in Chicago, you're on WNYC. Hi, Sarah. Oh, Sarah disappeared. Let's try Terry in Brooklyn. Terry, you're on WNYC. Can you hear me?

Terry: Yes, Brian, how are you doing?

Brian Lehrer: Good. Tell us your story.

Terry: Yes, Brian. Okay, first time caller, and thanks for taking my call.

Brian Lehrer: You're welcome.

Terry: My grandson, my daughter, my grandson, he's a type 1 diabetic, and they live in Georgia. Two weeks ago, my daughter went to fill his prescription for his insulin, and they said he cannot do it since the government Trump cut all the Medicaid coverage and everything like that, and she had to pay $700 just to get his insulin, and she has to do that at least every two weeks.

Brian Lehrer: Covered by Medicaid, did you say?

Terry: Yes, whatever. He had his coverage, he had. Through the government, he had coverage, and when she went to refill his prescription, they said they cannot do it, and they cannot help her. She had to pay $700 to get a insulin.

Brian Lehrer: I'm so glad you called, Terry. Of course, I'm not happy about this story at all, but I'm really glad you raised this category because, Sarah, I think we've been talking about private insurers exclusively up until now. Does the same trend also apply to government insurance, Medicaid, Medicare?

Sarah Kliff: Yes, so we do know a decent amount about Medicare Advantage, that is the private insurers who essentially provide health benefits to seniors who can decide whether to opt into the public program, or the private program, and there's a similar pattern among those insurers. Some academic researchers found a 15% increase in Medicare Advantage denial rates, I believe at a similar time period. I don't want to give you the numbers. I don't have them right in front of me.

In Medicaid plans, less of an increase, but the number, the denial rates just tend to be slightly higher in Medicaid plans, than they are in private insurance, and that is-- We're also at a moment when Medicaid is about to be cut very, very significantly, because of the bill the Republicans passed. It will be interesting to see how that plays out with denial rates, and whether you see any changes come out of that.

Brian Lehrer: Can you give any advice to that caller? Because that story, if it's the way he said it, sounds so extreme. We're talking about a type 1 diabetic child running out of insulin, and the pharmacy saying it wasn't covered.

Sarah Kliff: Yes, I mean, my first stop would absolutely be calling my health insurance plan to ask what the heck is going on. That's clearly unnecessary medication. Nobody's overusing or abusing insulin, so my very first step would be going to the Medicaid plan, whatever government office you work with, or like our other caller, Annie, reaching out to a Congressman, reaching out to an insurance regulator, because it definitely sounds like something is going wrong there that should be remedied.

Brian Lehrer: Yes, and if it's Medicaid, Terry, if you're still listening, even call you a member of Congress, and that person may be hearing that you're talking about a kid with type 1 diabetes needing insulin, and whatever the bureaucracy is doing to block delivery of that insulin, maybe even your member of Congress will intervene. Since it sounds like it's a government program, I hope that helps.

Is RFK Jr talking about any of this? He's not a friend of the pharmaceutical industry, so he says. This is Health and Human Services regulatory area, I guess. Have you heard anything from the new administration?

Sarah Kliff: This just is not an area of focus for RFK. His interest in health care seemed to lie in different places than insurance regulation. Obviously, he's quite interested in the Make America Healthy movement again, with the focus on vaccines, and the work he's doing on food dyes. When I watched his confirmation hearing, and it seemed like he had some pretty fundamental misunderstandings of what Medicaid and Medicare are, and how they work, so I don't know what to expect in this area.

Also, a lot of the regulation of these large employer plans, they run through a bunch of different agencies, the Department of Labor, Treasury, so it really need to be a multi-pronged effort if the administration did decide these denials were a priority. You are seeing actually a little bit of movement, I should say, from the insurance plans themselves. A month ago, a coalition of large health insurance plans said they were going to reduce their use of something called prior authorization, essentially, making the doctor get permission to order a drug before they could prescribe it.

That's been a real frustration point for a lot of doctors, a lot of patients, and they voluntarily came forward, I think, in part, because they're getting so much heat over [unintelligible 00:19:44] their use of prior authorization to say, "Within the next year or two, we're really going to ratchet it down, and we're really going to make it much faster, so people are getting quicker determinations," so you're seeing a little voluntary movement on the insurance industry. Less of a regulatory appetite from the Trump administration so far.

Brian Lehrer: Yes, and I guess if there's anything to say about RFK Jr's prior relationship to the pharmaceutical industry, it's not that he thought, or has been vocal about them denying prescriptions too much, as opposed to thinking that they over prescribe.

Sarah Kliff: Exactly, right. This doesn't seem to fit quite naturally into the set of issues that he's interested in.

Brian Lehrer: Ending on just a few points that may help people further when they run into this adjacent to something you said before, the health news site KFF released data in January that showed patients appealed denials only 1% of the time, but when they did, about half were accepted, so more encouragement to appeal. You also cite some pushback from UnitedHealthcare in your article, pushback that says, "Most rejected claims were followed up with another claim that was then approved," so whatever the root is to that secondary claim, don't give up, folks.

You close your article with the story of a doctor who appealed his prescription drug denial, and after his insurance refused to pay for an inhaler, he wrote a 14-page letter to the insurer and state regulators contesting it. The next day, it was overturned, and he was granted what they called a courtesy exemption, so just finish up, Sarah, by explaining what a courtesy exemption is, and if you can get your doctor-- It sounds like that was for that doctor themselves.

Sarah Kliff: Yes.

Brian Lehrer: Their own prescription, but can you get your doctor to do something like that? Maybe not 14 pages, but for you?

Sarah Kliff: [chuckles] Yes. No, I mean, that person was very specifically well-positioned to file this appeal. He's actually-- He was a former insurance executive. He's a doctor, and now he runs a business that is exclusively focused on helping people appeal denied claims, so he was the person to take on this task. If you are not that person, it's not-- I will say I'm not exactly clear on what a courtesy exemption is. This is the phrase that was used to me by the insurance plan. It sounded like they were saying they were making a one-time exception for this.

Brian Lehrer: You're a doctor, you give us a lot of business, we'll let you get away with this one.

Sarah Kliff: For the rest of us, I would say, definitely enlisting the help of your doctor is a good tactic. I think the thing a lot of people find tricky though is doctors are busy, right? Most of us don't have a physician who's going to write us a 14-page letter to appeal a denied claim, but I think doctors are used to getting requests from patients for some kind of medical necessity letter that would really bolster your appeal to the insurance company that you do need this medication.

Brian Lehrer: Yes, and doctors who I talk to, say the bane of their existence these days is dealing with insurance companies, which doesn't mean they don't do it. It means they're having to bake this in to their expenses.

Sarah Kliff: Exactly.

Brian Lehrer: As part of their practice, because they care about their patients. We will leave it there with Sarah Kliff, Investigative Health Care Reporter for The New York Times, who wrote the other day about the increase in denials by insurance companies for prescription drugs prescribed by your doctor. Sarah, thank you so much for sharing it with us.

Sarah Kliff: Yes, thanks so much for having me.

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