How to Fight a Health Insurance Denial With a Little-Known Tool

Summary

Podcast Summary: Paper Trail – “How to Fight a Health Insurance Denial With a Little-Known Tool”
ProPublica | May 28, 2026 | Host: Jessica Lussenhop

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Episode Overview

This episode delves deeply into the labyrinthine world of health insurance denials in the U.S., following one woman’s battle to get life-saving mental health care covered for her husband. Through investigative reporting and personal storytelling, the show spotlights a rarely known but crucial tool for overturning denials: the "external review." Guided by ProPublica’s Jessica Lussenhop and reporter Dua Aldib, we follow Teresa and her husband (“Elle”) through a harrowing journey that exposes not only the system's flaws but also what it takes to win—and what winning really looks like.

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Key Discussion Points & Insights

The Unfolding Crisis and Insurance Maze

• Teresa’s Story Begins

  • Teresa reaches out to ProPublica reporter Dua Aldib after her husband’s mental health crisis resulted in two suicide attempts and a $100,000+ battle with Highmark Blue Cross Blue Shield over denied coverage.
  • Teresa records every call, tracks every document, and repeatedly appeals insurance denials (03:21–04:08).

• The Emotional and Financial Toll

  • The couple’s background: college sweethearts, successful in work and marriage, blindsided by a mental health crisis during the pandemic and the combative insurance process.
  • “We're best friends on top of everything else, you know, I would describe our life as genuinely happy.” – Elle (06:16)

• Navigating Denials

  • Despite dire psychiatric need and multiple medical professionals recommending inpatient treatment, insurance denies coverage as “not medically necessary.”
  • “I am infinitely curious what credentialed individual made that decision that. That is not medically necessary.” – Teresa (20:12)

• The Documentation Strategy

  • Teresa’s meticulous recordkeeping: recording calls, organizing files and letters—paralegal skills as survival toolkit.

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The Secret Door: External Reviews

• The Breakthrough Discovery

  • Buried on page 62 of her insurance booklet, Teresa discovers her right to request an “external review”—an independent, third-party review legally binding on the insurer (21:36–21:59).
  • Industry insiders call it “one of the industry’s best kept secrets” (04:49, 22:45).

• Obstacles to Accessing External Reviews

  • Even when the right is listed in denial letters, insurance representatives may tell members that it doesn’t apply—sometimes almost running out the clock on deadlines (23:03–23:51).

• The Odds

  • “Only about 1 in 10,000 patients eligible for an external review actually uses one.” (24:04)
  • Most people don’t appeal initial denials, let alone reach this step, due to energy-draining bureaucracy.

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The Human Element: Dr. Neil Goldenberg

• Meeting the Reviewer

  • The external review lands on the desk of Dr. Neil Goldenberg, a psychiatrist moved by Teresa’s meticulous documentation and devotion (26:56–28:03).
  • “I knew he was this man who had a wife that loved him enough to put an inordinate amount of work into advocating for him. And I wanted them to know that somebody cared about that.” – Dr. Goldenberg (30:19).

• A Compassionate Decision

  • Dr. Goldenberg calls Teresa, tells her he’s overturning the denial, and acknowledges her exhaustive efforts:
    • “He wanted to let her know that he sees her and he sees how ridiculous the system has been to her. And he told her that he was going to approve the appeal, and he thanked her for all of her hard work.” – Dua Aldib (31:07)
    • "I was just kind of shocked, honestly, that someone cared enough to call…" – Elle (31:28)

• Why External Review Matters

  • This determination is binding; insurers can’t appeal. This is part of why external reviews are seldom advertised (31:56).

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Aftermath and Impact

• Resolution—but at a Cost

  • Highmark ultimately reimburses $70,000 after Dr. Goldenberg's ruling (35:44).
  • The process is exhausting; the emotional fallout persists.
  • “I’m tired. I’m still tired, actually. Today just—it was exhausting, both mentally and physically.” – Elle (33:21)
  • “We couldn’t really work on us because my focus was getting these appeals approved and these claims paid.” – Elle (37:41)

• Expert Insight: Not a Silver Bullet

  • “For this outcome to have happened, so many things had to align… Teresa had to be this, you know, paralegal background wife who is super determined... And then, I think, the review has to land in an inbox like Dr. Goldenberg’s, someone who really takes the time…” – Dua Aldib (36:00)
  • Not all external reviewers are as diligent; sometimes they’re “rubber stamps” (36:47).

• Call to Listeners:

  • The show provides resources for appealing denials and highlights the importance of understanding one's rights.
  • “Appeal, appeal, appeal, appeal, appeal.” – Insurance experts (34:03).

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Notable Quotes & Memorable Moments (with Timestamps)

• The Kafkaesque Maze

  • “It’s like she’s stuck in a maze.” – Jessica Lussenhop (03:49)
  • “No, that isn’t just frustrating. That is criminal.” – Teresa (21:07)

• On External Reviews

  • “It’s one of the industry’s best kept secrets.” – Dua Aldib (04:49, 22:45)

• On Bureaucratic Fatigue

  • “It was exhausting, both mentally and physically. I have had no time to process really anything that happened because I’ve just been running from one fire to another.” – Elle (33:21)

• On the Odds

  • “Only about 1 in 10,000 patients eligible for an external review actually uses one.” – Dua Aldib (24:04)

• On What It Takes to Win

  • "You fight all these fights, you play the game, you try to follow all the rules through the maze, you even find the secret door. And then the person waiting on the other side of that door, it better be Patch Adams." – Jessica Lussenhop (36:47)

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Key Timestamps

• Teresa’s Introduction & Start of Battle: 01:44–04:32
• Detailed Account of Husband’s Crisis & System Denial: 07:04–13:54
• Discovery and Explanation of External Review: 21:36–22:46
• Insurance Roadblocks/Evidence of Systemic Problems: 17:19–20:03
• Dr. Goldenberg Enters the Story: 26:44–31:28
• Resolution, Reimbursement & Aftermath: 31:56–39:10
• Discussion of Broader Implications and Takeaways: 34:03–36:47

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Conclusion

This episode is a powerful expose on the toll and odds of fighting health insurance denials—especially for mental health. It spotlights the external review as a crucial but underused tool, demonstrates the extreme persistence required to win, and puts a face on both the victims and rare heroes within the system. The emotional aftermath for families like Teresa’s remains long after the fight is over, a sobering reminder that the need for structural change is urgent.

For more resources or to learn how to request an external appeal, see the episode’s show notes or visit propublica.org.

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If you or a loved one is struggling with a mental health crisis, you can call the suicide and crisis hotline at 988.

Transcript

[Jessica Lessenhop]

ProPublica Investigative journalism in the public Interest. As a heads up, this story contains detailed descriptions of suicide attempts. Please take care while listening. Here's a little secret. Anybody can do investigative journalism. Say you're facing a problem, something that feels really unfair. Maybe you start researching, diving deep, documenting what's happening. Maybe you find out something that other people didn't know. Congratulations. You might be an investigative reporter at ProPublica. A lot of our investigations start with tips from people like you. The things people tell us can lead to some pretty wild revelations if it turns out whatever you're struggling with is hurting a lot of other people too. Calling it out can lead to real world change. Change that prevents anyone in the future from going through the same painful experience. It's honestly kind of incredible. A couple of years ago, my colleague Dua Aldib heard from someone just like that.

[Dua Aldib]

I think it was maybe September of 2024 that we got this tip through a call out.

[Jessica Lessenhop]

Dua covers healthcare. And along with some other colleagues at ProPublica, she sent out a call out to the asking for tips. She was specifically curious about mental health because that's an area where people really have trouble getting their health insurance to cover treatment. She basically said, hey, does anyone have any stories about this? And that's when she heard from Teresa.

[Dua Aldib]

I think at the most basic level, she said that this horrible thing happened with her husband and she's in this fight with insurance company.

[Jessica Lessenhop]

Teresa's husband was having a severe mental health crisis. She was worried he was going to take his own life and she'd gotten him into an inpatient treatment facility and

[Dua Aldib]

the insurance company was still denying his coverage.

[Jessica Lessenhop]

She was fighting them for almost $100,000.

[Dua Aldib]

That, to me was just mind blowing.

[Jessica Lessenhop]

Teresa reached out to Dua because she thought the company was deliberately trying to avoid paying a legitimate claim.

[Dua Aldib]

I have heard of cases where insurance companies deny coverage, but this seemed really hard for me to wrap my head around. And so I think I really wanted to understand how this could happen.

[Jessica Lessenhop]

And there was one other very important thing Teresa mentioned. She had been documenting every interaction she had with the health insurance company.

[Insurance Representative]

Do you mind holding a few more moments?

[Dr. Neil Goldenberg]

If we get disconnected, I'll definitely call you back, but I hoping that won't happen again. Sorry.

[Jessica Lessenhop]

Recording every single phone call.

[Teresa]

Okay, sure. Yeah, I'll hold.

[Insurance Representative]

Anything? Tired of waiting for your EOD to come in the mail? Why not elect to receive your EOB

[Jessica Lessenhop]

via email on these calls that Teresa sent Dua? I feel like I'm right there with her sitting on these endless holds, they remind me of every crappy customer service experience that I've gone through.

[Teresa]

So this is the third time that I'm calling back and I'm in the

[Dua Aldib]

middle of a pill.

[Jessica Lessenhop]

But on these calls, Teresa is fighting for life or death medical care and for her and her husband's financial future.

[Teresa]

I also didn't receive information about the code that was on one of the

[Jessica Lessenhop]

denied benefits, and she keeps hitting all these roadblocks.

[Teresa]

Okay, well, another part of this mystery is this very same service was issued under an earlier claim number.

[Jessica Lessenhop]

It's like she's stuck in a maze.

[Teresa]

I've been given an adverse benefit determination. I've lost an appeal that I didn't

[Dua Aldib]

even know was there.

[Teresa]

I didn't have a case number, and now I'm just being told, too bad.

[Jessica Lessenhop]

A maze that at times seems designed to confuse and discourage her and ultimately convince her to quit.

[Teresa]

I will hopefully get a call by noon and. And if not, I will call back again.

[Jessica Lessenhop]

But she was determined to find her way out.

[Teresa]

I would suggest you get your attorneys involved because I'm certainly getting mine involved.

[Insurance Representative]

Okay, I understand. I understand. That makes sense.

[Jessica Lessenhop]

Dua started following Teressa's journey, not knowing where it would lead. But after months of wandering around in this maze, Teresa would find a secret place door. It was on page 62 of her insurance coverage booklet.

[Dua Aldib]

Somebody told me it's one of the industry's best kept secrets.

[Jessica Lessenhop]

And in this story, we're going to tell you that secret because if you're ever in a similar fight with your health insurance company, you might need to know this, too. It does kind of feel a little bit like, oh, this could happen to anybody.

[Dua Aldib]

I think that's exactly it. I think that's exactly it. Jessica. This could happen to anybody.

[Jessica Lessenhop]

I'm Jessica Lessenhop and this is Paper Trail. Right after reporter Dua Aldib read Teresa's message about her insurance fight, she reached out.

[Dua Aldib]

So I emailed her right away, and I was like, can we talk?

[Elle]

What would you like to know about me other than chaos I find myself immersed in at the moment?

[Dua Aldib]

What about your life pre chaos?

[Elle]

Can you just tell us a little about kind of, you know, where you live, what you do, what your life is like? Okay, I live in Raleigh.

[Jessica Lessenhop]

Tell me a little bit about this couple.

[Dua Aldib]

So they met in college, and the night that they met, her husband walked up to her, kind of trying to strike up a conversation, and she politely tells him, like, look, I'm waiting for someone. And then he responds right, away. And he's like, I could be someone. And really from that night, like that was it. They fell in love.

[Elle]

We're best friends on top of everything else, you know, I would describe our life as genuinely happy.

[Dua Aldib]

Teresa is kind of more introverted and her husband is like this funny guy who can like work a crowd. And they end up building this software consulting company together. So then she goes back to school and she becomes a paralegal and then she becomes their kind of in house legal expert. They're just these college sweethearts who built their lives together.

[Elle]

I mean, I think most people would joke, you know, we've been married for 15 years and we still hold hands in public. People would say, that's so funny. And they'd be like, what? And they're like, well, you're still holding hands like you were on a first date.

[Insurance Representative]

And

[Dua Aldib]

okay.

[Jessica Lessenhop]

Dua talked to Teressa's husband and he gave Dua permission to let her tell his story. He didn't want his real name or voice used. So we're going to call him Elle. Elle started struggling with his mental health around the pandemic, which I think is not surprising.

[Dua Aldib]

Right. We saw mental health needs go up exponentially during the pandemic. And I think the things that we least expect are what trigger it. And so I think for them it was looking for a house. That's what really set things off.

[Elle]

He decided to buy a house in probably the craziest housing market that I can remember in my lifetime. And it was challenging. And we lost like two or three homes and money.

[Dua Aldib]

And I think for Al, financial matters especially would cause him a lot of anxiety and stress.

[Elle]

But then he just kind of kept looking at houses. He just kept looking.

[Dua Aldib]

They find a house, but it needed work. They argued a lot. They argued about money. They argued about him not willing to go get help. That's when Theresa starts seeing her husband unravel.

[Elle]

I just like, I can't do this anymore. Like, I just can't. And we separated.

[Dua Aldib]

She was no longer able to recognize the man that she fell in love with. And so then she moves out.

[Elle]

And then that is, I guess for him, he just snaps.

[Dua Aldib]

And so then he agrees to get help. And they had started him on an antidepressant. And that's when they started to get really worried because, you know, he called the doctor and said, like, look, I'm not getting better. In fact, I'm getting worse. And he meets with a psychiatrist and he tells him, my heart is racing, like, my legs feel weak and I'm waking up at 2:30 in the morning

[Elle]

and he was having these really terrible nightmares.

[Dua Aldib]

And so then, you know, the doctor asks him about whether or not he's considering ending his life. And he tells him he felt anxious and hopeless, but he was too scared to die.

[Jessica Lessenhop]

Dua spoke to Teresa and her husband several times about what happened next. The details you're about to hear are difficult, and Dua thought long and hard about whether to publish them. So did our team. But the details are important because this is the situation that doctors from the health insurance company were evaluating to decide whether the treatment was medically necessary.

[Dua Aldib]

So two days after he met with his psychiatrist, he goes into the garage and he swallows a bottle of sleeping pills, chases them down with some bourbon.

[Elle]

And then he sat in the car, in the garage with the car running

[Dua Aldib]

and he closes his eyes and he thinks that's going to be the end. Teresa calls 911 because she, she was trying to get ahold of him.

[Elle]

I went over immediately, called the ambulance,

[Dua Aldib]

the paramedics arrive and they take him to the hospital.

[Elle]

And he was involuntarily committed at that time to like, a county level facility near us.

[Jessica Lessenhop]

I must assume that when he starts needing this care, you know, I don't know that probably coverage was the first and foremost concern. The first and foremost concern was, I'm gonna go get some help.

[Dua Aldib]

Yeah, he had great coverage. He had highmark, Blue Cross, Blue Shield, you know, like really good private insurance. And so I think that they had just assumed that we've been paying into this and we've been paying our premiums. And so now when we need it, they're going to pay us back. And then about a week later, the judge decides that he can be released to Teresa's care under two conditions. That he has to see a therapist and a psychiatrist and that he has to move back in with Teresa. She loved him, so of course she agreed.

[Elle]

He was home for four days, and then one morning I woke up, he was not here.

[Dua Aldib]

So she goes downstairs and she sees him leaning over the kitchen sink, and she walks closer to him. And then she sees a knife and it's covered in blood. And then as she gets closer, she sees blood, like, pouring out of his neck and all over his sweater and like, coming from his wrists. And she immediately goes into like, saving mode. And she just keeps asking like, did you do this to yourself? Did you do this to yourself? And then finally he responds and he's like, yes.

[Jessica Lessenhop]

Oh my God.

[Dua Aldib]

And she calls 911 again. And she's, you know, kind of trying to explain what's happening and asking for help.

[Elle]

And he tells her, just, just let me die. Just let me die. Just leave me alone and let me die. That's all he would say over and over and over.

[Jessica Lessenhop]

Are you okay?

[Dua Aldib]

I'm okay. For readers to understand how egregious it is for the insurance companies to have denied this. They have to know the details. Like, they have to know how serious it was. And then despite that, the insurance company still denies it. So after the second attempt, he agrees to get treatment and they send him to a residential facility. Then while he was there, he starts displaying signs of psychosis, hearing voices.

[Elle]

He would call me and swear they were trying to frame him for being a drug addict and a murderer. I mean, it was just, it was out there.

[Dua Aldib]

Teresa is seeing that, like, not only is he not getting better, he's getting worse. So then she calls a friend who's

[Elle]

a social worker, and I asked them, where's the best place to go? We'll go anywhere.

[Dua Aldib]

And so her friend recommends the Menninger Clinic in Houston. And so she books a flight for the two of them to Texas.

[Insurance Representative]

If you are going to pre certify a mental health or substance abuse admission, press one pre certification.

[Elle]

I called my insurance, the first call I ever had with them. And I recorded because I'm like, this is probably not going to go easily to get the pre authorization to move him, because in my coverage booklet it says, I need to call first.

[Jessica Lessenhop]

This call. This is the moment Teresa enters the health insurance maze. Months after Al's mental health struggles first began.

[Teresa]

We want his care to be moved to the Menninger Clinic in Houston, Texas, which is both out of state and out of network for our particular coverage. But I know, I know I have to get pre approved or pre certified to do that.

[Insurance Representative]

Okay, so he's currently in a patient center.

[Dua Aldib]

At first it seems like it was going to be fine. Insurance gives her the go ahead.

[Elle]

We get the letter that says this stay has been authorized.

[Dua Aldib]

And they say that he is pre authorized to get into the new hospital.

[Elle]

I'm like, all right, great.

[Dua Aldib]

So one of the first things that they do is do this genetic testing and it reveals that, like, he could have an adverse reaction to the first antidepressant that his doctor had put him on. And so that for both of them felt like, oh, maybe that is why things spiraled so quickly so fast. They're both kind of feeling like things are taking a turn for the better.

[Elle]

Then I get the first denial letter.

[Dua Aldib]

So that first denial letter was from highmark blue cross blue shield, and they were denying Elle's first residential treatment facility, the one that he was taken to after his suicide attempt, saying that he now has a balance of $30,000. Oh, my God. For that care. The denial wasn't, you know, because of some kind of, like, plan restriction. It was because doctors working for Hyamark determined that the care was not medically necessary.

[Jessica Lessenhop]

Not long after that, Teresa got a denial for the second treatment facility with the same justification. His care was not medically necessary. And I want to read directly from Elle's denial letter, because you just have to hear it for yourself. The request for coverage for an acute inpatient psychiatric hospitalization is not approved. You reported history of depression and anxiety symptoms. You are not suicidal, homicidal, or psychotic. You are able to care for your personal needs. You are not a danger to yourself or others. Your admission is not medically necessary. You could have been safely managed at a lower level of care. Teresa reads this and is like, absolutely not.

[Elle]

Oh, no. Yeah, this is. This is gonna be a fight. I just feel it.

[Jessica Lessenhop]

Her next move is to appeal the

[Dua Aldib]

denial, and she begins tracking and documenting everything. She's, like, taking meticulous notes. You know, she's got file folders. Everything is really, like, organized. Her bills, her letters, her appeals requests,

[Jessica Lessenhop]

and she keeps recording her calls.

[Insurance Representative]

Please continue to hold and be assured that your call will be answered in the order it was received in these

[Jessica Lessenhop]

first calls to highmark reps. Teressa isn't even getting to the heart of the matter, why the care was denied. She keeps running into these roadblocks.

[Teresa]

I called in yesterday, trying to get some EOBs that we cannot download that have been denied or not paid, files that won't download. I have been trying to fax over some information regarding a claim, and the fax. Fax number provided in the letter I received is. Doesn't work.

[Jessica Lessenhop]

It keeps giving an error, incorrect fax numbers.

[Teresa]

It says the file is corrupted when you try to open it, Even though it looks like it successfully downloads corrupted

[Jessica Lessenhop]

files sent over email.

[Insurance Representative]

Did you check in your spam and your junk, all of that?

[Jessica Lessenhop]

Yes.

[Teresa]

We didn't get anything.

[Jessica Lessenhop]

Missing letters Highmark claims to have sent.

[Teresa]

And when I logged into that today, all of the prior communications regarding these appeals was gone.

[Jessica Lessenhop]

At one point, Teressa gets a denial that has a bizarre error in it.

[Dua Aldib]

And the denial letter says, it was determined that your newborn does not meet the criteria for coverage of an inpatient hospital admission. And I'm, like, newborn. Like, newborn.

[Jessica Lessenhop]

What in the world?

[Dua Aldib]

Yeah. I think at the beginning, Teresa was really trying to work with the representatives and kind of trying to give them benefit of the doubt. I noticed when I was listening, there were please and thank yous that she would add to the calls.

[Insurance Representative]

I'll be right back.

[Elle]

Okay, thank you.

[Insurance Representative]

I'll give you a call and let you know.

[Elle]

Okay, great.

[Teresa]

Thank you.

[Dua Aldib]

Okay. Thank you.

[Jessica Lessenhop]

Hi.

[Insurance Representative]

Thank you. Bye. Bye.

[Jessica Lessenhop]

Oh,

[Dr. Neil Goldenberg]

wow.

[Dua Aldib]

Which, you know, disappeared once we get later into the process.

[Insurance Representative]

How are you doing today?

[Teresa]

I've been better. Yeah,

[Insurance Representative]

I understand.

[Dua Aldib]

The thing about Teresa is she's a bulldog.

[Teresa]

I never got any notice of any other appeal being accepted. I never got a case number.

[Dua Aldib]

She is not someone who is going to let insurance win.

[Teresa]

So this kind of seems like it's by design at this point to avoid paying behavioral health claims. That's what it feels like.

[Insurance Representative]

Yeah. I understand your frustration. I. I get where you're coming from.

[Teresa]

So what is my remedy?

[Dua Aldib]

There was one call where the representative is like, oh, you didn't get that letter.

[Insurance Representative]

So even, like, the acknowledgement letters, you say you said you didn't receive those either.

[Teresa]

Oh, I absolutely didn't.

[Dua Aldib]

And then she just gets really, really, really upset.

[Teresa]

So it's up to me to do the. To handle the appeal, which it's very hard for me to do when there are roadblocks being purposefully erected for me, such as not being notified that I have a case number and that I'm supposed to send stuff in and I'm on a deadline because I absolutely would have sent that stuff in. I haven't. I am very curious. Under what scenario exactly? A person who has tried to kill himself twice within the span of a week is denied an inpatient behavioral health treatment when every doctor that saw him said he needs to be in a residential treatment program. I am infinitely curious what credentialed individual made that decision that. That is not medically necessary.

[Insurance Representative]

Yeah, I definitely understand. That's very frustrating.

[Teresa]

No, that isn't just frustrating. That is criminal. That isn't just frustrating. That is criminal. That is a breach of agreement for services that are. That is many things.

[Dua Aldib]

And Tarcell's like, oh, hell no. Like, not only am I going to appeal, I'm going to keep appealing. Keep appealing and keep appealing. And then as she's, like, reading the coverage booklet, which, you know, I've never done before, like, read an entire, like, insurance company's coverage booklet, she read from start to finish, and deep in the

[Jessica Lessenhop]

booklet, that's where she finds it, a way out of the maze. Something called an external review.

[Dua Aldib]

And that's kind of like this light bulb.

[Jessica Lessenhop]

This is it, the secret door. An escape hatch from the labyrinth of denials, lost paperwork, and endless customer service calls.

[Dua Aldib]

So we know about the regular appeals, right? When an insurance company denies you, then you can go back back to the insurance company and appeal it and say, you know, look, I think that you made the wrong decision. Here's why. The external appeal or external review goes outside the insurance company. If the insurance company has already determined, you know, once or sometimes twice that they're not going to pay for treatment, then maybe consumer. It would be helpful for you to go to someone independent of the insurance company, have them look at all the medical evidence and see if they decide the same thing. But they're so. Because I think most people don't know about them. It's, you know, somebody told me. It's like one of the industry's best kept secrets.

[Jessica Lessenhop]

Turns out this external review was mentioned not only in the coverage booklet, but also in Teresa's denial letters.

[Insurance Representative]

But then that letter is incorrect. I guess it's just a standard letter.

[Teresa]

Okay, so the letter I just got that says I now have a right to ask for an external independent review is wrong?

[Insurance Representative]

Yes, yes. That's just a generic letter.

[Dua Aldib]

She's like, what do you mean? So of course she fights them on it.

[Insurance Representative]

The rights have been exhausted, unfortunately.

[Teresa]

How have they been exhausted when I've never asked for an independent outside review when it says I have the right for that in my coverage booklet. That's the part I don't understand. I don't know how exhausted. Some. Something I haven't used.

[Dua Aldib]

And then they tell her, okay, fine, we'll let you file one, but you know, you have to get it to us before 5pm which was, I want to say, like less than two hours from when she was on the phone with them. And she, she was like, okay, I see you.

[Teresa]

Okay, I will get that to you before 5 o' clock for sure.

[Insurance Representative]

Okay, sounds good. Thank you so much.

[Elle]

Bye.

[Jessica Lessenhop]

Dua read a study that found only about 1 in 10,000 patients eligible for an external review. Actually uses one. Teresa was 1 out of 10,000 people who asked to pass through the secret door.

[Dua Aldib]

So she files this request for an external review and it goes to a third party.

[Jessica Lessenhop]

After filing the external review, Teresa saw a missed call on her phone from that third party.

[Elle]

Oh, maybe they need something.

[Jessica Lessenhop]

The reviewer left her voicemail. And when Teressa listened, I was,

[Elle]

I was just Kind of shocked.

[Dua Aldib]

Had it not been for this doctor, the outcome could have been completely different.

[Jessica Lessenhop]

That's next.

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[David Remnick]

Right now, we are living through some of the most tumultuous political times our country has ever known. I'm David Remnick, and each week on the New Yorker Radio Hour, I'll try to make sense of what's happened alongside politicians and thinkers like Cory Booker, Nancy Pelosi, Liz Cheney, Tim Waltz, Ketanji Brown Jackson, Newt Gingrich, Robert F. Kennedy Jr. Charlamagne, tha God, and so many more. That's all in the New Yorker Radio Hour, wherever you listen to podcasts.

[Jessica Lessenhop]

So Teresa has filed this external review, does not have high hopes, and then she gets this voicemail. So who called her? Who left this voicemail?

[Dua Aldib]

The call was from a doctor she's never heard of or talked to before. His name is Dr. Neil Goldenberg. He's a psychiatrist from Ohio who works part time as an external reviewer, and he was the one who was assigned her case. So I called Dr. Goldenberg and he told me the email took him by surprise.

[Dr. Neil Goldenberg]

It immediately jumped out at me that there was this, like, highly organized summary from a family member. And that's not usually the case when

[Dua Aldib]

I get these and he starts going through it and he automatically could tell something was different about this. A lot of the reviews that come in are usually from hospitals or doctors. And then also just how meticulous it was.

[Dr. Neil Goldenberg]

The information was presented as sort of like exhibit A, exhibit B. And I've never seen that type of language outside of, you know, court lawyer shows that everyone.

[Dua Aldib]

And so for Dr. Goldenberg, he's like, was this a lawyer? And then he goes to the bottom of the letter and he sees Theresa's name And then he decides, you know what, I'm gonna call her.

[Dr. Neil Goldenberg]

It's just. That just seemed like the right thing to do.

[Dua Aldib]

Dr. Goldenberg believes deeply in people getting the care that they need. He went to medical school and he reads that book by Dr. Patch Adams, which I don't know if you remember. I'm old enough to remember when the movie came out, but, you know, he's that.

[Jessica Lessenhop]

Of course I remember. What's your name?

[Insurance Representative]

Cameron.

[Dua Aldib]

Hi, Cameron. I'm patching. He's the doctor that was played by Robin Williams. And, you know, he was really fixated on kind of infusing humor and compassion in medicine without any care whatsoever for insurance. So Dr. Goldenberg reads his book and he is inspired.

[Dr. Neil Goldenberg]

You know, vast swaths of our population were uninsured. And so, you know, I just couldn't get over how unfair that was. Wanted to be part of the good guys fighting to change that.

[Dua Aldib]

He decides to specialize in community psychiatry. But also, he's a doctor, his wife's a doctor. They had huge amount of debt from medical school that they were like, okay, maybe a side job could also, you know, help.

[Jessica Lessenhop]

So it's like a side hustle.

[Dua Aldib]

Yeah. Basically, he decides to kind of take on this side job as a third party reviewer. And he made sure to tell himself, like, if I feel pressure to only side with the insurance company is like, I'm out. So this is who he is at his core.

[Jessica Lessenhop]

This is who he is when this email presumably lands in his lap.

[Dua Aldib]

Yes. Yep, exactly.

[Jessica Lessenhop]

So what did Dr. Goldenberg make of the fact that Elle's care was denied based on medical necessity?

[Dua Aldib]

I mean, I think as a psychiatrist, when you're reading all of this medical evidence and you're reading what the doctors are saying, I think he was really taken aback that this was still denied. I think it's the same reaction that a lot of us have when we hear this story. But I think we have it more maybe from an emotional perspective. He actually has the medical training to back it up and saying, no, this was unfair. The claim should have been covered.

[Dr. Neil Goldenberg]

I couldn't just see it as a case on a sheet of paper. I knew he was this man who had a wife that loved him enough to put an inordinate amount of work into advocating for him. And I wanted them to know that somebody cared about that.

[Jessica Lessenhop]

I think there's something. I just want to make a note of it, that there is something so fascinating about, like, at the end of this very inhuman bureaucratic process, at the very end of this sort of like, Vortex, someone like Dr. Goldenberg's on the other end.

[Dua Aldib]

I think that's exactly right. In the voicemail, he says very plainly at the beginning, hello, my name is Neil Goldenberg.

[Dr. Neil Goldenberg]

Hello, my name is Neil Goldenberg.

[Insurance Representative]

I am reviewing.

[Dua Aldib]

I'm reviewing an insurance claim for your husband. And then he went on to tell her that he's read the extensive paperwork that she provided, and he wanted to let her know that he sees her and he sees how ridiculous the system has been to her. And he told her that he was going to approve the appeal, and he thanked her for all of her hard work.

[Elle]

I was just kind of shocked, honestly, that someone cared enough to call and took the time to read everything I had put together. Was there a party that felt like Highmark could somehow still override this or. Yeah, yeah. Like, I had to. I'm like, yeah. And I need to make sure this is binding on Highmark. If there's any way at all they could disagree with this, I'm sure they will.

[Dua Aldib]

I think that's what's so powerful about these external reviews, is that the determination is binding. So whatever the third party reviewer decides, that is legally binding. And so the insurance company cannot argue and cannot appeal. And what experts told me is that's also part of the reason that these external appeals are not as well known, because if the external reviewer decides in your favor, then that's it.

[Elle]

And I think I did call them once I got the letter and said, I got this letter, you know, what are. What comes next? And on the phone they go, oh, well, yeah, we'll be processing the payments over the next week or two. Now that you've won the appeal. I mean, is this the point where you're like, now I need to, like, get back to our. Our life and our relationship? Yeah, I mean, that was kind of my thought at that point, was, I can finally rest.

[Jessica Lessenhop]

This is supposed to be the magic moment. Teresa solved the Maze to Dr. Goldenberg. She had definitively proved her case. The insurance company was wrong. But I was surprised when I heard this call of Teresa telling DUA about it. She does not sound like a woman who just beat the hardest level of our American healthcare game.

[Elle]

I'm tired. I'm still tired, actually. Today just. It was exhausting, both mentally and physically. I have had no time to process really anything that happened because I've just been running from one fire to another.

[Jessica Lessenhop]

Affordable Care act insurers, the big ones like Blue Cross and Cigna, deny an average of 1 in 5 claims. For some, it's 1 in 3. Less than 1% of people actually appeal those denials. A tiny fraction of those people will get far enough in the maze for an external appeal.

[Dua Aldib]

Most people don't appeal because it's a pain and because it takes a lot of time and you're already exhausted and you're already dealing with a million other things. So in talking to insurance experts, what they advise is appeal, appeal, appeal, appeal, appeal.

[Jessica Lessenhop]

DUA asked to interview representatives of Highmark Blue Cross Blue Shield about all of this. They didn't make anyone available to talk, but they sent a statement saying that they were complying with all state and federal laws pertaining to their members mental health services. Elle also sent the company written permission to speak about his case with dua, but they did not answer her questions. In their response, they wrote that they take their members experience, quote, seriously. We recognize and sincerely regret, however, any times when the prior authorization and claims processing experience can be challenging and frustrating, even when patients are treated and claims are paid, as was true in this particular case. We also acknowledge that small errors made by physicians and or members can lead to delays and initial denials, which are corrected on appeals, as we believe may have been the case here. Elle's whole treatment, all the hospitalizations, would be billed at more than $220,000. Teresa and Elle had initially been charged and had to pay more than $95,000 of that out of pocket. But in the end, after Dr. Goldenberg's determination, Highmark reimbursed them $70,000. So this story makes you think like, oh, this is like a magic. It sounds like a silver bullet. It sounds like a magical spell that you can cast on this whole process or something that everybody should know about this and be doing it. Is that, is that real?

[Dua Aldib]

I don't think so. I think for this outcome to have happened, so many things had to align, right? Teresa had to be this, you know, paralegal background wife who is super determined and does not give up and basically spends months and months working on this appeal. And then I think the review has to land in an inbox like Dr. Goldenberg's, someone who really takes the time to read and weigh the medical evidence before making a determination. And what I have heard from some experts in the field is that like, that's not always the case with external reviewers. Some of them are rubber stamps for the insurance company.

[Jessica Lessenhop]

That's what really stuck with me about Teresa and Elle's experience. You fight all these fights, you play the game, you try to follow all the rules through the maze you even find the secret door. And then the person waiting on the other side of that door, it better be Patch Adams. Where are Theresa and El now? How are they doing?

[Dua Aldib]

So I think there is, like, this temptation to walk away feeling like. And they lived happily ever after. And I think I kind of was feeling that a little bit. And I was like, oh, great. Well, you guys got reimbursed. Elle, you know, got discharged. He's back at work. He, you know, finished his treatment. Like, everything is great. But I think they're still trying to put, you know, the pieces of their marriage back together.

[Elle]

We couldn't really work on us because my focus was getting these appeals approved and these claims paid.

[Dua Aldib]

The two of them went back to couples counseling because I do think they still love each other very much. But this takes a toll.

[Elle]

Has there been any more talk about, like, what the future will hold for the two of you? I, you know, I guess in our couple session, that was sort of why we were there.

[Dua Aldib]

Yeah.

[Elle]

Like, what are. What are we doing now? But I believe the step now is I have to process all the trauma because I haven't done that. I'm just now starting to do that because I finally feel like I don't have any insurance to fight and can now take the time to do that. It's just like, we've been on hold.

[Dr. Neil Goldenberg]

Foreign.

[Jessica Lessenhop]

That could help a lot of people. DUA wrote a whole story about how you can file an external appeal and what denials are eligible. You can find the link in our show notes if you have a tip, something you know about that you think we should look into, or something that might lead to information that could help other people reach out to us. Go to propublica.org tips to find out how to contact us securely. And finally, if you or a loved one is experiencing a mental health crisis, you can call the suicide hotline at 988-just-a heads up, we will be off next week, but back the week after with a whole new episode. Thanks for listening.

[Gabrielle Burbet]

This episode was produced by me, Gabrielle Burbet, and edited by Katherine Wells.

[Dua Aldib]

Engineering and sound design by David Herman.

[Gabrielle Burbet]

Music by Julian Sartorius, Filippo Ansaldi and Simone Sims Longo with additional music from Epidemic Sound.

[Dua Aldib]

The rest of our team is Julia Longoria and Savvy Robinson.