\u201cI could have gotten really ill,\u201d Kovitch said.<\/p>\n
But Kovitch\u2019s insurer denied coverage for the walk-in visit. Its reason? She hadn\u2019t obtained a referral or preapproval for it. \u201cYour plan doesn\u2019t cover this type of care without it, so we denied this charge,\u201d a document from her insurance company explained.<\/p>\n
Health insurers have long argued that prior authorization \u2014 when health plans require approval from an insurer before someone receives treatment \u2014 reduces waste and fraud, as well as potential harm to patients. And while insurance denials are often associated with high-cost care, such as cancer treatment, Kovitch\u2019s tiny tick bite exposes how prior authorization policies can apply to treatments that are considered inexpensive and medically necessary.<\/p>\n
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Pledging To Fix the Process<\/strong><\/p>\n The Trump administration announced this summer<\/a> that dozens of private health insurers agreed to make sweeping changes to the prior authorization process. The pledge includes releasing certain medical services from prior authorization requirements altogether. Insurers also agreed to extend a grace period to patients who switch health plans, so they won\u2019t immediately encounter new preapproval rules that disrupt ongoing treatment.<\/p>\n Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a June press conference that some of the changes would be in place by January. But, so far, the federal government has offered few specifics about which diagnostic codes tagged to medical services for billing purposes will be exempt from prior authorization \u2014 or how private companies will be held accountable. It\u2019s not clear whether Lyme disease cases like Kovitch\u2019s would be exempt from preauthorization.<\/p>\n Chris Bond, a spokesperson for AHIP, the health insurance industry\u2019s main trade group, said that insurers have committed to implementing some changes by Jan. 1. Other parts of the pledge<\/a> will take longer. For example, insurers agreed to answer 80% of prior authorization approvals in \u201creal time,\u201d but not until 2027.<\/p>\n Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, told KFF Health News that the changes promised by private insurers are intended to \u201ccut red tape, accelerate care decisions, and encourage transparency,\u201d but they will \u201ctake time to achieve their full effect.\u201d<\/p>\n Meanwhile, some health policy experts are skeptical that private insurers will make good on the pledge. This isn\u2019t the first time major health insurers have vowed to reform prior authorization.<\/p>\n Bobby Mukkamala<\/a>, president of the American Medical Association, wrote in July<\/a> that the promises made by health insurers in June to fix the system are \u201cnearly identical\u201d to those the insurance industry put forth in 2018<\/a>.<\/p>\n \u201cI think this is a scam,\u201d said Neal Shah, author of the book \u201cInsured to Death: How Health Insurance Screws Over Americans \u2014 And How We Take It Back<\/a>.\u201d<\/p>\n Insurers signed on to President Donald Trump\u2019s pledge to ease public pressure, Shah said. Collective outrage directed at insurance companies was particularly intense following the killing of UnitedHealthcare CEO Brian Thompson in December. Oz specifically said that the pledge by health insurers was made in response to \u201cviolence in the streets.\u201d<\/p>\n Shah, for one, doesn\u2019t believe companies will follow through in a meaningful way.<\/p>\n \u201cThe denials problem is getting worse,\u201d said Shah, who co-founded Counterforce Health<\/a>, a company that helps patients appeal insurance denials by using artificial intelligence. \u201cThere\u2019s no accountability.\u201d<\/p>\n Cracking the Case<\/strong><\/p>\n Kovitch\u2019s bill for her clinic appointment was $238, and she paid for it out-of-pocket after learning that her insurance company, Anthem, didn\u2019t plan to cover a cent. First, she tried appealing the denial. She even obtained a retroactive referral from her primary care doctor supporting the necessity of the clinic visit.<\/p>\n It didn\u2019t work. Anthem again denied coverage for the visit. When Kovitch called to learn why, she said she was left with the impression that the Anthem representative she spoke to couldn\u2019t figure it out.<\/p>\n \u201cIt was like over their heads or something,\u201d Kovitch said. \u201cThis was all they would say, over and over again: that it lacked prior authorization.\u201d<\/p>\n Jim Turner, a spokesperson for Anthem, later attributed Kovitch\u2019s denials to \u201ca billing error\u201d made by MaineHealth, the health system that operates the walk-in clinic where she sought care. MaineHealth\u2019s error \u201cresulted in the claim being processed as a specialist visit instead of a walk-in center\/urgent care visit,\u201d Turner told KFF Health News.<\/p>\n He did not provide documentation demonstrating how the billing error occurred. Medical records supplied by Kovitch show MaineHealth coded her walk-in visit as \u201ctick bite of left lower leg, initial encounter,\u201d and it\u2019s not clear why Anthem interpreted that as a specialist visit.<\/p>\n After KFF Health News contacted Anthem with questions about Kovitch\u2019s bill, Turner said that the company \u201cshould have identified the billing error sooner in the process than we did and we apologize for the confusion this caused Ms. Kovitch.\u201d<\/p>\n Caroline Cornish, a spokesperson for MaineHealth, said this isn\u2019t the only time Anthem has denied coverage for patients seeking walk-in or urgent care at MaineHealth. She said Anthem\u2019s processing rules are sometimes misapplied to walk-in visits, leading to \u201cinappropriate denials.\u201d<\/p>\n She said these visits should not require prior authorization and Kovitch\u2019s case illustrates how insurance companies often use administrative denials as a first response.<\/p>\n \u201cMaineHealth believes insurers should focus on paying for the care their members need, rather than creating obstacles that delay coverage and risk discouraging patients from seeking care,\u201d she said. \u201cThe system is too often tilted against the very people it is meant to serve.\u201d<\/p>\n Meanwhile, in October, Anthem sent Kovitch an updated explanation of benefits showing that a combination of insurance company payments and discounts would cover the entire cost of the appointment. She said a company representative called her and apologized. In early November, she received her $238 refund.<\/p>\n But she recently found out that her annual eye appointment now requires a referral from her primary care provider, according to new rules laid out by Anthem.<\/p>\n \u201cThe trend continues,\u201d she said. \u201cNow I am more savvy to their ways.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n![](\"http:\/\/www.dangeladvertising.com\/wp-content\/uploads\/2025\/11\/Kovitch_06-scaled.jpg\")
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