Facing health issues is stressful. Being denied by your insurance for crucial claims is added worry.
On top of that, 18% of insured adults reported experiencing denied claims in 2023. Of those denied certain prescription drug coverage, nearly half said they simply go without.
Donna Staat is trying her best to stay active and enjoy her early 60's. But she said knee pain is making that difficult.
"It wasn't anything major, but unfortunately, right after I had a surgical repair or just an arthroscopy to kind of investigate it, I broke my leg," Staat said.
This led to arthritis. Her doctor called for a drug called Zilretta, but she said her insurance denied the prescription.
Ultimately, she ended up paying for it not once, but twice.
Staat said she and her doctor made multiple phone calls to her insurance company with no outcome. Eventually, she ended up paying $1,500 out of pocket for the second treatment.
Dr. Richard Lehman is an orthopedic surgeon who said he spends an exorbitant amount of time battling insurance companies.
"I think a lot of times the insurance company won't approve a drug or an injection or more physical therapy," Lehman said. "And a lot of that is just algorithms, right? They say you've had 12 visits or the algorithm tells us you don't need any more and we're just not going to approve any more. And a lot of times what'll happen is when you appeal and they understand that this is the process, they'll agree."