Marketing executive Mathew Evins endured eight years of chronic back pain before doctors agreed he needed surgery in 2024. However, his insurance repeatedly denied coverage, requiring additional physical therapy and delaying treatment for seven months despite warnings about potential permanent damage.
Evins represents millions of Americans who face insurance denials or delays for medically necessary care. According to surveys, 73 percent of Americans say delays and denials by insurers pose a major problem in health care access.
Experts note that while providers seek to offer necessary treatment, insurers act as gatekeepers whose decisions can override doctors’ recommendations. Katherine Hempstead, senior policy officer at the Robert Wood Johnson Foundation, described patients’ frustration when insurers deny treatments—citing examples like migraine Botox therapy—even when clinical benefits are evident.
In response to these systemic challenges, companies like Sheer Health have emerged to assist patients in contesting insurance denials. Co-founder Ben Howard explained that Sheer Health manages insurance claims and appeals to remove the burden from patients. Customers either pay a monthly fee or a percentage of recovered funds.
Sheer Health’s intervention was critical for Evins, who credited the company with reviewing his policy, submitting expedited appeals, and communicating closely with his healthcare providers to resolve authorization issues. After Sheer Health’s involvement, Evins finally underwent surgery in October and reports significant improvement.
Hempstead acknowledged Sheer Health’s success but characterized the need for such companies as symptomatic of a larger health care system failure, where navigating insurance is complex and adversarial. She called it an instance of “buying insurance for your insurance,” underscoring systemic inefficiencies.
Evins emphasized the human cost of insurance delays: “It’s people’s lives that these insurance companies hold in the balance. Take that seriously.”
Why it matters
Insurance claim denials can cause serious delays in essential medical treatment, risking patients’ health outcomes. The rise of advocacy firms like Sheer Health signals a demand for better support systems but also highlights underlying problems in health care coverage processes. With millions uninsured or underinsured, these hurdles intensify disparities in access to timely care.
Background
Insurance companies routinely require preauthorization and may deny or delay coverage based on their policies, often conflicting with provider recommendations. This dynamic creates friction between patients, providers, and insurers. According to data, approximately 20 percent of insurance claims are initially denied, prompting appeals or alternative funding strategies. Efforts to reform prior authorization rules continue amid ongoing debates about balancing cost control with patient access.
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