Her Surgeon Said She Needed The Operation. UnitedHealthcare Said No.

Robin Ginkel is a 43-year-old early childhood special education teacher in Minnesota’s Twin Cities area. In February 2023, she pulled her back as she was picking up a kid, causing a disc to bulge. The pain was and still is extraordinary, and Ginkel has suffered from a significantly reduced range of movement ever since. 

Her doctor recommended surgery. UnitedHealthcare says she doesn’t need it, despite the fact that her pain is often intense and she can’t be as physically active as she needs to be for her job. 

Her surgeon recommended a laminectomy, which removes a portion of the disc to deal with debilitating back pain, and sent a prior authorization request to UnitedHealthcare. A 2015 study showed that most laminectomy patient’s reported substantially less back pain.

Nevertheless, the insurer said it wouldn’t cover it.

At first, her surgeon thought the denial was because of a coding issue and expressed optimism that the denial would be reversed on appeal and that the surgery would bring the relief she needed. “My doctor said ‘We know the process, so we'll just put in an appeal. We'll recode this stuff, and it shouldn't be a big deal.’”

Then the second denial came back. 

“My surgeon continued to think he could get the company to cover the procedure, but United refused to reconsider the denial. It went through three denials, and the frustrating part is that United won't talk to me about any of them.”

While the issue of prior authorization in Medicare Advantage has begun to get significant media attention, people enrolled in employer-sponsored plans also frequently experience denials of medically necessary care. A 2022 report from the consultancy group Crowe LLP found that the dollar value of denials had increased to 2.5% of hospitals’ gross revenue in August 2022 from 1.5% in January 2021 — a huge 66% jump in less than two years. The growth in prior authorization denials likely helped drive a sixfold increase in hospital bankruptcies in 2023 from the prior year. A 2023 survey from the American Medical Association found that 33% of physicians had found that prior authorizations contributed to a major medical event. 

Robin Ginkel

This year, even as it has faced a major ransomware attack that could end up costing it and many health care providers billions of dollars, UnitedHealth, with its market capitalization of $543 billion larger than the gross domestic product of Austria, spent more than $2.2 billion buying back its own stock to artificially inflate the value of each share. (The company bought back more than $9 billion of its own shares between March 2023 to March 2024.) The mega-conglomerate has paid or announced more than $5 billion in dividends. Its most recent dividend of $2.10 per share reflects a 68% increase since 2021. And the company’s CEO, Andrew Witty, made over $23 million in 2023. UnitedHealth’s medical costs payable liability — the amount it says it owes for medical costs but hasn’t paid yet — has grown by nearly 50%, from $21.9 billion in 2021 to $32.4 billion at the beginning of this year according to the company’s financial statements. With that money sitting in a money market account, UnitedHealth can earn lucrative returns of as much as $1.5 billion annually with current interest rates.

The average physician processes 45 prior authorization requests per week. In August, looking at Medicare Advantage, KFF found that the percentage of prior authorizations denied by insurers jumped from 5.8% in 2021 to 7.4% in 2022–a 28% leap in a single year.

Not Even a Written Explanation

“With the second denial, they didn't even send me a letter,” Ginkel told HEALTH CARE un-covered. “I couldn't even get the written explanation of why it was denied. They said that they only give those to the doctor's office.

“And so with the third appeal, my surgeon wrote a two-page letter describing what was wrong with me, why he was recommending it and what the procedure would be. Now we're getting into the time frame where we worry about permanent damage,” Ginkel said.

The appeal was denied a third time. Then it went to an independent medical review, and Ginkel was denied again. That “external” review was performed by Dane Street LLC, a Boston-based medical review firm that has attracted scrutiny in recent years.

Dane Street had an employment relationship with Spyros Panos, who lost his license to practice medicine, was convicted twice of health care fraud and was sentenced to 54 months in prison. In 2018, Dane Street disclosed to the Iowa Attorney General’s office that health care information of “less than 100” Iowans had been sent to Panos. Most of Panos’ work that could be found resulted in denials, Bloomberg found in 2018. Panos had also done reviews for UnitedHealth when working for a different company, in one case denying a man needed rehabilitation services that could permanently affect his ability to speak. “He cannot currently speak, and he would have continued to develop his speech had he received speech therapy early on,” Bloomberg quoted the family’s lawsuit as stating. 

A subsequent lawsuit, in December 2022, identified Dane Street’s medical director as Marvin Friedlander. Friedlander’s license was suspended by the state of New Jersey for three years starting in 2014 because he “engaged in, or condoned his agent to engage in on his behalf, a pattern of misrepresentation in order to optimize a revenue source from a succession of... health care service entities in which he or his then-wife owned significant beneficial interest.” 

In May 2018, a jury awarded a patient of Dr. Friedlander’s $4.5 million for medical malpractice. According to the lawsuit, Friedlander had mispositioned a spinal fusion screw in the patient’s back, resulting in “pain and suffering and loss of enjoyment of life.” 

UnitedHealth did not answer questions and Dane Street did not respond to requests for comment from HEALTH CARE un-covered.

Ginkel is now seeking a second opinion to counter Dane Street’s denial. As she battles UnitedHealth’s sprawling bureaucracy — the company says it has 440,000 employees — Ginkel faces debilitating pain. “It's a pain that wraps around my ribs. It's on my left side and it's a bulging disc. So in the morning, it's usually not terrible, but by the end of the day, if I, especially if I've been mobile and doing stuff and upright, then it gets worse throughout the day. So for the last year and a half, I've been on a restricted work schedule. I can do three non-consecutive days a week with a 10-pound lifting restriction.”

Ginkel said UnitedHealth's relentless delays not only are hurting her physical health but her mental health as well.

“The longer this goes on, the things that I used to do to help my mental health, I can't do. I've been dealing with a lot of anxiety. This last summer, I've been feeling a lot more depressed because things are starting to feel just more and more hopeless,” she said.  

Ginkel is now working with People’s Action to try to force UnitedHealth to pay for her care. 

"Robin's case is a grievous injustice, and sadly one of many. Companies like UnitedHealth routinely put profits ahead of patient care, and the result is that people like Robin have to live in debilitating pain,” said Aija Nemer-Aanerud, the Healthcare for All Campaign Director at People's Action. “At People's Action, we've seen dozens of cases like Robin's. We fight back by organizing ordinary people to take on the insurance industry's greed – and we get results, helping people get the care they need. But we don't have the capacity to do this for every person denied care by their private insurer. The system needs to change."