Navigating Insurance Disputes: A Time-Consuming Battle
Erin Massey, a biotech scientist, has recently found herself with a second job: persuading her insurance provider, Cigna, to cover a necessary insomnia medication.
Previously, Premera, her insurer through a different employer, covered the drug. Despite her doctor’s repeated confirmation of its medical necessity through numerous forms, Cigna has consistently denied coverage for Quviviq, she reports.
Massey estimates dedicating 8-10 hours weekly to securing medication coverage, involving calls to Cigna, form completion, appeal writing, and researching methods to demonstrate the drug’s essential role in her health. Her situation is common, with Americans collectively spending at least 12 million hours each week contacting their health insurers, according to data.
This stems from the complexity of the U.S. healthcare system, which often mandates pre-authorizations for procedures—insurer approval confirming medical necessity and coverage—that frequently result in denied care. A 2024 study indicates that around 45% of insured working-age adults received a medical bill or copayment for services they believed should have been free or covered. Furthermore, 17% of adults, like Massey, experienced denied coverage for doctor-recommended care.
Consequently, individuals must engage in disputes with insurance companies, submit appeals, and invest substantial time monitoring claim statuses. This time burden, termed “”sludge”” by Atlantic journalist Annie Lowredy and Stanford professor Jeffrey Pfeffer, negatively impacts both the economy and individual health.
This “sludge” may be increasing. Research suggests that insurers are becoming more sophisticated in using technology to deny claims, according to Sara R. Collins, a study author. She notes the frustration of paying premiums yet being denied necessary care, which erodes trust in the healthcare system and discourages people from seeking medical attention.
A study in found that 22% of cancer patients experienced delays in prior authorization and other administrative hurdles that prevented them from receiving prescribed care.
Cigna informed TIME that they cannot comment on individual cases without a signed HIPAA waiver. However, Massey stated that after TIME inquired about her case, she received an email stating that the original denial was overturned and that Cigna had informed her doctor of the coverage. Cigna stated that they “don’t want anyone spending hours on the phone working to understand their benefits or to resolve issues” and have recently launched an initiative to simplify processes.
It is for insurance companies to reverse denials following media or social media attention. However, not everyone can rely on media inquiries to overturn their denials.
This healthcare-related time tax also incurs significant costs in lost productivity. Pfeffer estimates the annual cost of employees dealing with health insurance companies at . Employees often use work time to address insurance issues, as claims administrators are typically available only during business hours.
Since health insurance is often employer-provided, employees may become more dissatisfied with their company when insurance issues arise. Pfeffer notes that individuals spending more time contacting their health insurer are more likely to be dissatisfied with their workplace, miss workdays, and experience burnout compared to those without insurance issues. He estimates the productivity cost of this reduced satisfaction at .
Despite the high cost of this time tax, few solutions are on the horizon. The No Surprises Act, effective January 1, 2022, aimed to reduce patient time spent contacting insurers by protecting them from out-of-network emergency bills. The Affordable Care Act also includes guidelines on required coverage.
However, few national regulations govern insurer response times or mandate disclosure of claim denial rates or paperwork errors.
Pfeffer urges employers to proactively hold insurers accountable for wasting employee time. Since employers hire insurers to provide employee benefits, they should ensure the benefit is genuinely useful. By demanding data on claim denial rates and appeal frequency, employers can incentivize better insurer behavior.
“Your employer hires your insurance company, and so your employer should say to the insurance company, ‘We’re going to hold you to a set of performance standards,’” he says. “‘And if you don’t meet our performance standards, we’re going to fire you.’”
Erin Massey has gained extensive experience in dealing with insurers, learning strategies like preventing representatives from ending calls before her questions are answered and demanding written documentation.
Having sought an insomnia cure for eight years and finally finding the right medication through trial and error, Massey was particularly frustrated by Cigna’s repeated denials.
Before Cigna’s reversal, her next step was an external appeal for outside doctors to review her case. At the time, she suspected her insurer didn’t anticipate her pursuing it. Previously, she wouldn’t have expected to get this far either.
“I have spent entire days just trying to figure out what the next step is,” she says. “It’s been a lot of work.”
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