The U.S. healthcare system is confusing and overwhelming, and consumer confidence in it is eroding. A recent Gallup survey found that Americans’ view of the quality of healthcare has declined to a 24-year low. In addition, Americans are enraged by insurance practices they characterize as “Delay, Deny, Defend”. The recent murder of insurance CEO Brian Thompson on the streets of New York City unleashed a torrent of anger fueled by heart-wrenching patient stories of insurance denials that resulted in worsening illnesses, financial ruin and even death.
Eileen Filliben is a patient advocate with personal experience overcoming the many complexities and inequities of the insurance system. “Insurance denials aren’t just frustrating—they can be life-altering,” she explains. In one instance, she received a bill for thousands of dollars from an anesthesia practice after one of her many surgeries. “I had done my research ahead of time and made sure that the surgeon and the hospital were in network. How could I possibly know that the anesthesiologist – whom I had no control over selecting – didn’t accept my plan?” Filliben shared. “Should I have looked up at him from the operating table just before going under and asked, ‘You do participate in my insurance plan, right?’” It took over a year of advocating for herself and making countless phone calls, but she finally persuaded the insurance company to, in her words, “do the right thing”.
Filliben, who formerly practiced law, understands that many patients wouldn’t have been as tenacious as she was. Unfortunately, insurance companies are betting that patients and doctors alike will back down. According to a recent survey, fewer than half of people who experienced insurance denials and billing issues actually fought the decisions. In a particularly telling example, according to the American Medical Association (AMA), in 2022, only 10% of prior authorization denials were appealed, but over 80% of those appeals were either partially or wholly successful.
Filliben is now on a mission to empower others to be their own advocates for quality care. She has developed a step-by-step framework designed to help patients take control of their healthcare journey, overcome insurance obstacles, and secure the quality care they deserve.
This article explores her advocacy framework, the strategies it offers, and the impact it’s having on patients navigating a broken system.
Understanding the Insurance Barrier Crisis
Insurance companies often act as gatekeepers to healthcare, determining what procedures, medications, or treatments are covered. Unfortunately, their decisions are frequently based on cost-saving measures rather than patient well-being. Having faced multiple insurance denials throughout her healthcare journey, Filliben understands how these barriers can leave patients feeling powerless.
She explains that the denial process is often opaque and discouraging. “Patients are left in the dark about why their care is being denied, and many give up before appealing,” she says. Insurance denials can prevent patients from receiving the care they need, wreak havoc on their finances and even cause disability or death. According to data from the AMA, among the doctors recently surveyed about prior authorizations:
- 94% said that the prior authorization process (prior auth) delays patients’ accessing necessary care.
- 19% said prior auth resulted in a patient being hospitalized.
- 13% said prior auth caused a life-threatening event or required intervention to prevent permanent impairment or damage.
- 7% said prior auth led to a patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death.
Furthermore, denials cause real financial distress. Over 20 million Americans currently have medical debt, and healthcare costs are a leading cause of bankruptcy in the US. In addition, over a quarter of adults skip some form of medical treatment because they can’t afford it.
Marginalized groups suffer from higher rates of claim denials. A recent study found that Asian, Hispanic, and non-Hispanic Black patients are about twice as likely to experience claim denials compared to their non-Hispanic white counterparts. Additionally, lower-income patients are 43% more likely to have their claims denied than higher-income patients.
In addition to these consequences on patients’ physical health and finances, insurance denials can cause patients significant worry and anxiety.
Recognizing these challenges, Filliben created her advocacy framework to demystify the process and empower patients to take action. “No one should feel powerless in their healthcare journey,” she says. “With the right tools and support, patients can push back and get the care they need.”
The Advocacy Framework: A Step-by-Step Guide
At the heart of her mission is a step-by-step advocacy framework that equips patients with the skills and knowledge to navigate insurance obstacles effectively. The framework is built on three key pillars: understanding, communication, and persistence.
The first step is education. Filliben emphasizes that patients need to thoroughly research the plan options they’re considering whether the plan is offered through their employers, the Affordable Care Act’s healthcare exchange, or Medicare supplement providers. When evaluating choices, it’s important to consider three things. First, consider your own healthcare needs such as current medical conditions and prescription drug usage. Second, evaluate what the plan offers such as participating doctors, well benefits for proactive doctors visits, and coverage for prescription drug costs as well as how much it will cost overall including premiums, copays, and out-of-pocket maximums. “Insurance policies are definitely not one-size-fits-all,” Filliben says. “It’s important to determine your needs and make sure the plan you select is a good fit.” Third, understand how the claims process works and what your options are if a claim is denied. While this research can be time consuming, it can literally save patients thousands of dollars each year. “Insurance policies are intentionally complex, but patients need to familiarize themselves with the details,” she explains. By reviewing their plans, patients can identify potential roadblocks and prepare for appeals.
Communication is the second pillar of the framework. Patients are encouraged to document every interaction with their insurance provider, from phone calls to written correspondence. “Keep detailed records—it’s your best defense against denials,” she says. Additionally, she advises patients to ask their doctors for support. A phone call or letter from a provider explaining the medical necessity of a treatment can often sway insurance decisions. “Your doctor is your ally,” she adds. “Their voice carries weight.” Filliben also recommends asking for help if you’re confused or overwhelmed. “The HR department, friends, family members, church groups, nonprofits geared towards helping senior citizens, and local libraries can also lend a helping hand.”
Persistence is the final pillar. Most patients with denied claims (69%) do not know that they have appeal rights, and the vast majority (85%) do not file formal appeals. The fewer appeals, the more the insurance companies profit. Unfortunately, that’s all part of their business plan. “Insurance companies count on patients giving up, but persistence pays off,” she says. The framework provides actionable tips for making persuasive phone calls, drafting effective appeal letters, navigating the appeals process, and, if needed, escalating cases to higher authorities or external review boards. For example, many states offer help to patients with health insurance problems through Consumer Assistance Programs* (CAPs). Offering assistance by phone, mail, email and sometimes even in person, CAPs can be an invaluable ally helping patients get the benefits to which they are entitled.
Empowering Patients for Better Outcomes
This advocacy framework isn’t just about overcoming insurance barriers—it’s about restoring a sense of control and agency to patients. Filliben believes that empowering patients to take charge of their healthcare journey leads to better outcomes, both physically and emotionally. “When patients feel confident in their ability to advocate for themselves, it changes everything,” she says.
Through her keynote speeches, workshops and coaching programs, Filliben provides real-world strategies and personalized support. Her advocacy framework also highlights the broader systemic issues at play. By sharing her insights and raising awareness, she hopes to drive meaningful reform in the insurance industry. “Patients shouldn’t have to fight this hard for care,” she says. “But until the system changes, we need to equip them with the tools to win those fights.”
Conclusion
Eileen Filliben’s step-by-step advocacy framework is more than a guide—it’s a lifeline for patients navigating the complexities of the U.S. healthcare system. By focusing on education, communication, and persistence, her approach empowers patients to overcome insurance barriers and secure the care they need.
“Our healthcare system is flawed, but patients have more power than they realize,” she concludes. “With the right strategies and support, they can advocate for themselves and get the care they need, have paid for, and deserve.”