This Week in Healthcare News (The Stuff That Actually Matters to You)

Hey, it's April.

So I was scrolling through healthcare news this week like I do every week, and honestly? Most of it is for hospital executives and insurance company lawyers. Snoozefest.

But then I found a few things and thought, wait, people need to know about this.

So here we go. Four things from this week that you should actually care about if you're sitting on a medical bill you can't pay or if you've been trying to get care and keep hitting a wall.

There Are Now Apps That Will Fight Your Insurance Company for You

OK so this one is kind of wild.

Two new companies just showed up and their whole thing is fighting insurance denials on your behalf.

One is called Claimable. You pay $50, tell them what got denied, and they write a really strong appeal letter and send it to your insurance company. About 3 out of 4 people who use it get their denial flipped. Three out of four! They've helped about 4,000 people so far.

The other one is called Sheer Health. You literally just take a picture of your bill and they handle everything for $40 a month or a cut of whatever money they recover.

Here's why this matters. Insurance companies deny hundreds of millions of claims every year. And almost nobody fights back. When people do fight back on their own, the insurance company still says no more than half the time. These new tools are specifically built to change that.

If you have a denial letter sitting in a pile somewhere because it felt too overwhelming to deal with, this is your sign to go dig it out.

Medicare Patients in 6 States Are Waiting Way Longer for Care, and It's Because of AI

This one makes me genuinely cranky.

Since January 1st, the federal government has been running a test program called WISeR. It uses AI to add prior authorization requirements (basically, asking for permission before you can get care) to 13 types of procedures in traditional Medicare that never needed it before.

The states where this is happening are Ohio, Arizona, New Jersey, Oklahoma, Texas, and Washington.

Before this program, some of those approvals took 2 to 3 days. Now hospitals are reporting waits of 2 to 8 weeks. Patients are being rescheduled over and over while they sit in pain. A senator called it "AI being used as a denial device," which, yeah.

The good news is that when she asked the HHS Secretary about it, he called the delays "unacceptable" and said they'd fix it. So there's some pressure happening.

If this is affecting you or someone you love, ask your doctor or hospital whether WISeR is causing the holdup. And honestly, calling your U.S. Senator's office is not as scary as it sounds. It has worked for other patients.

The Middlemen Who Control Your Drug Prices Are Fighting to Stay Hidden

OK I need to explain what a pharmacy benefit manager is because they sound boring but they are very much affecting your wallet.

PBMs are companies you've probably never heard of, but they sit between your insurance company and the drug company and they decide a lot about what you pay for your prescriptions. They're kind of like the toll booth in the middle of the road.

The Trump administration proposed a rule that would force PBMs to tell your employer (and by extension, you) exactly what they're charging for drugs. Transparency. Kind of a no-brainer, right?

This week, the PBMs filed hundreds of letters saying the rule is illegal and should be blocked. Drug companies also don't want their prices disclosed.

On the flip side, companies like Mark Cuban's Cost Plus Drugs are cheering the rule on.

Why should you care? If this transparency rule passes, it gets a lot harder for PBMs to overcharge in secret. If it gets blocked, the mystery continues and your prescription costs probably stay higher than they should be.

The Law That Was Supposed to Stop Surprise Bills May Have Made Some Bills Bigger

You might have heard of the No Surprises Act. It became law in 2022 and the idea was good. If you go to an in-network hospital but end up getting treated by an out-of-network doctor (which happens a lot, especially in the ER), you shouldn't get stuck with a giant bill for that.

New research out this week found something kind of unfortunate though.

For imaging services like MRIs and CT scans, prices after the law's dispute process have actually gone up. A lot. Like, before the law, imaging prices were roughly 200% higher than Medicare prices. Now, after arbitration under the new law, they're coming out at around 767% higher than Medicare prices.

The reason is complicated but basically: when providers and insurance companies can't agree, an arbitrator picks a price, and providers are winning those fights more than 90% of the time and they're asking for way more money.

So what does this mean for you? If you got a big out-of-network imaging or ER bill recently and thought the No Surprises Act protected you, check the details carefully. You can still negotiate. You can still ask for an itemized bill. You can still ask about financial assistance. A big number is not a final number.

OK, That's It for This Week

Quick version:

• Got a denied claim? Look up Claimable or Sheer Health.

• On traditional Medicare in one of those 6 states and waiting forever for a procedure? Ask why and call your senator if you need to.

• Confused about why your prescriptions cost so much? The fight over PBM transparency is happening right now and it matters.

• Got a big out-of-network bill and thought you were protected? Read that bill carefully and don't just pay it.

You have more options than the system wants you to think you do. I promise.

Talk soon, April