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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. Let’s meet somebody. 

Ron Lieber: I’m Ron Lieber. I write the “Your Money” column for the New York Times. I write all sorts of books, and I live in Brooklyn, New York.

Dan:  Ron’s specialty is beating the system: How to not pay more than you really need to. His most recent book — about paying for college — we’ve practically worn out our copy around my house. 

Now, it’s possible Ron’s not the most prominent journalist in his household. A major Hollywood movie a few years ago had Zoe Kazan starring as Ron’s wife, Jodi Kantor. 

Zoe Kazan as Jodi Kantor: Hi. We’re from the New York Times. I believe you used to work for Harvey Weinstein.

Dan: She was one of the reporters who exposed the movie producer Harvey Weinstein’s history of sexual assault, and helped kick start the Me Too movement. I mean, that’s hard to beat. 

In 2024, Jodi was diagnosed with breast cancer, and she got scheduled for surgery at Memorial Sloan Kettering on a Monday morning in December.

Ron Lieber: And she was doing all the things you’re supposed to do to get ready for surgery. She did the meditation for a week and, you know, she wound down everything at work she went away for a couple days with friends.

Dan: So on Saturday, two days before surgery, Jodi is on that trip with friends. Ron spends the day with their 9-year-old, just the two of them.

Ron Lieber: And we get home and there’s a pile of mail and I put the 9-year-old to bed and I start going through the mail and there is a fat envelope from United Healthcare.

Dan: Ron says he suspects right away that it’s bad news about the surgery.

Ron Lieber: And sure enough it’s, you know, kind of pages of gobbledygook, but it’s clear from the cover page, that they’re issuing a partial denial, in effect, and we have, flunked partially, our prior authorization test.

Dan: Prior authorization. It rings a bell. He does a quick search to get his bearings– and quickly realizes: This is a HUGE phenomenon. It hasn’t hit him personally before, but it hits millions of people every year.

Ron Lieber: So at this point, a whole bunch of stuff goes through my head.

Dan: First, professional embarrassment. Ron’s a personal finance columnist at the New York Times. And he’s thinking: how could he have missed something that causes so much personal financial distress to so many people? 

Ron Lieber: I had that same feeling that I did in 2008.

Dan: When the financial crisis hit and he hadn’t seen it coming. 

Ron Lieber: Back in 2008. It was, you know, Ron, why did you not become an expert on mortgage securitization before now?

Dan: This time, it’s prior authorization. Ron manages to forgive himself pretty quickly on that score– and move on to more pressing concerns.

Ron Lieber: The first thing I gotta figure out is: What am I gonna say to Jodi?

Dan: Is he gonna crash her pre-op mellow she’s worked so hard for? 

And second: How worried should they be?

Ron Lieber: Should we show up on Monday? What’s the worst thing that can happen? And so I’m starting to do mental math, like what’s the rack rate for this procedure anyway, and I’m thinking, eh, probably 150- $200,000. Right?

Dan: Yeah, like real money. This is the point when a lot of people would decide to reschedule surgery. But Ron digs into the paperwork, and he can see this denial is a mistake. United isn’t even denying the reconstructive part of Jodi’s surgery — the part a plastic surgeon does. They’re denying the mastectomy itself.

That’s gotta be wrong. And Ron decides that is not going to stick.

Ron Lieber: These people are not going to win. I am going to win, because I’m Ron Lieber.

Dan: He’s a professional at beating the system. 

Ron Lieber: I’m gonna stand up for my wife.

Dan: And he’s not in this alone.

Ron Lieber: I work for a big company. We have excellent HR people. 

Dan: And he figures the hospital will hold up their end in this fight.

Ron Lieber: I imagine that there are 10, 15, 20 people at Memorial Sloan Kettering who do nothing but deal with nonsense, all day long. So one way or another, we’re gonna win.

Dan: One thing he says knows he WON’T do in this fight: Let on to anybody at the hospital or the insurance company that they should give him special treatment because he, you know, works for the New York Times.

Ron Lieber: We have the strictest ethics code, probably on the planet, right? We get fired for throwing our weight around. The moment you open your mouth at 1-800 United Healthcare and say, I work for the New York Times, stop messing around with me, you lose your job. There’s no second chances.

Dan: He DOES plan on taking notes. Because eventually, this could be a good story.

And I’ll just tell you right now. It was. Ron eventually put his family’s story in the New York Times, looking to help other people avoid — at the least — getting a scary notice that there’s some problem with their insurance with no time to do anything about it.

Hundreds of readers wrote back with their own stories, with suggestions, with complaints.

And Ron responded by coming back to the story with a tool he hoped people — actually people’s doctors — could use to prevent these kind of scary situations, at least some of them.

I freaking love it.

This is An Arm and a Leg — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the most terrifying, enraging, depressing parts of American life, and bring you something entertaining, empowering, and useful.

Jodi comes home from her trip with friends on Sunday. Surgery is scheduled for the next morning, first thing. Ron tells her the news. She hits the roof.

Ron Lieber: She’s not angry, she’s just sad and she’s stressed all the things that should not happen, right, when you’re going into major surgery. 

Dan: Meanwhile, Ron does what he can to get the insurance thing resolved. Which, on a Sunday, isn’t much. 

Ron Lieber: There’s this stupid appeal form that you can send to a supposed emergency fax line. So, you know, I download E-fax for the first time in 19 years, um, and send the fax off into the ether. Nothing happens.

Dan: Next morning, they show up for surgery, and once Jodi’s under anesthesia, Ron figures he’s got 6 hours to kill, maybe eight.

So he starts roaming the hospital campus, looking for someone who could explain what was up, and what to do.

Ron Lieber: So I was just showing up at desks saying, Hey, check out this love letter I got from UnitedHealthcare.

Dan: And the people at those desks are like, Oh wow– we got one of these TODAY? 

Because Ron and Jodi’s story was playing out against the backdrop of a much bigger story, one that had started just a few days before.

Jessica Tisch: In Midtown Manhattan, early this morning, 50-year-old Brian Thompson, the CEO of UnitedHealthcare was shot and killed in what appears at this early stage of our investigation to be a brazen, targeted attack.

News announcer: Protestors have targeted United Healthcare, which reportedly denies one of every three claims. 

News reporter: CBS news also confirms law enforcement found shell casings at the crime scene with the words deny, defend, and depose written on them.

Dan: Those words – “deny, defend, depose”– they suggested to lots of people that issues like prior authorization played a role in the killer’s motivation. 

And: Police were chasing the suspected shooter– later identified as Luigi Mangione– that very morning. So when Ron shows up at the billing office with his UnitedHealthcare denial…

Ron Lieber: People are like, oh, is he still on the loose? They just, just couldn’t believe that like this thing, you know, that Luigi was clearly upset about, right, was presenting itself in real time while he was still being chased. 

Dan: They also quickly reassured Ron about his immediate situation.

Ron Lieber: The nice woman in the billing office, you know, clicks a bunch of keys on her keyboard and she pulls it up and she said, oh yeah. She said, this isn’t gonna be a problem. She said, it may take a while. But don’t worry about it.

Dan: And she said something else that gets Ron’s wheels spinning.

Ron Lieber: She said, we got notice of this, you know, seven or eight days ago. If we had thought that there was gonna be a problem, we would’ve called you right away and told you not to come.

Dan: Ron was thinking: I sure wish you’d have given us a heads-up — and this kind of reassurance — before now.

Ron Lieber: I’m mad because we didn’t find out about it until 36 hours ahead of time when it was too late to do anything ’cause it was Saturday night and the surgery was Monday morning. So why didn’t you just tell me?

Dan: And he’s thinking: Ok, what’s my next move?

Ron Lieber: There are three voices played simultaneously in my head at a minimum. Number one is I’ve got a personal situation on my hand that I gotta solve, you know, as cheaply as possible. Number two, this is a story and I ought to be taking really careful notes, not just for my own purposes, but to make sure that I’ve documented things correctly and so that I can, you know, make the best case to the reader and, and the best case to the entities involved when it comes time to ask them some questions. And then number three. Try to avoid as best as I can, compromising the story in any way. Right? So like, don’t lose your temper, don’t lose your patience. Try not to even utter the words the New York Times…

Dan: How do you not blow your cover? 

Ron Lieber: Exactly. Right.

Dan: And there’s another thought: UnitedHealthcare is like the day’s top story. It’s coming out that this issue — pre-authorization — seems to be one of the alleged killer’s big issues.

Ron Lieber: So then I have a conversation with my editors while Jodi is still under anesthesia saying, I think I wanna write about this right now. Right? So this is like an hour before they catch Luigi. We’re right on the news here and I think this is the thing that he was upset about and we should just go with it. And my editor correctly said “no.” In order this for this to be, um, a useful story for the reader and to make sure we are 182% in compliance, you know, with our ethical responsibilities, we gotta let this thing play out to its conclusion on its own.

Dan: Ron went back to focusing on what really mattered to him right then. Which was not getting a scoop. 

Ron Lieber: I was not the main character here. My wife was the main character, right? She was sick. We were trying to fix her. It was a big deal. and I was sort of relieved, you know, at two in the afternoon when my editor was basically like, hit the pause button on this thing.

Dan: And there was more relief coming right up.

Ron Lieber: Jodi does great. The surgery’s successful. The surgeons did an amazing job.They were happy. Recovery was perfect. And we feel real good and so I’m sort of watching the mail.

Dan: Waiting for a super-high bill from the hospital. Or some word from United. Weeks go by. Nothing.

Ron does something that I wouldn’t expect — or necessarily advise — any normal person to do, any civilian: He keeps waiting. 

Partly ‘cause he’s super-confident that this will work out, and as a reporter, he’s gathering data: What would the system do, just left to its own devices?

Finally, on March 1st — more than two and a half months after Jodi’s surgery — Ron calls United. He says, ‘Hey, you said in early December that you were denying us, and I faxed you an appeal. I was just wondering: any news?’

Ron Lieber: And they took a look and they said, oh yeah. Um, the appeal on this one just went today to the physician, uh, who’s going to review the appeal. And I said, you guys waited like two and a half months to do that. And they said, yep. Um, uh, and I thought, well, okay.

Dan: Ron gets off the phone. Waits another few weeks before he finally calls again and hears from a United rep: Yep, this seems to be resolved.

Eventually, Ron gets a bill. It’s reasonable. He pays it. And switches to reporter mode.

So Ron the Reporter gets to ask the same questions Ron the Civilian has been asking all along.

Couldn’t someone have given him and Jodi a heads-up earlier?

Ron: Why did you not just tell us immediately, not through the United States Mail, you know, which some people don’t even open and some people don’t get. Why did you not send up some kind of flare? Send us a text. Call us on her phone, send an email, um, do all three at once. Like fly a freaking, you know, banner over Prospect Park saying, ‘Ron and Jodi call UnitedHealthcare right now. You have a problem.’ 

Dan: There’s a whole HUGE set of questions to ask about prior authorization itself — like, why on EARTH would you deny a mastectomy for breast cancer??

But for this story, Ron’s keeping a narrow focus.

Ron Lieber: The conversation I wanna have with UnitedHealthcare is not, you’re terrible. The system is terrible. Prior authorization is terrible. All I wanted to know was, given that we have to live within this system for now, why didn’t you call us?

Dan: The first words of that question– GIVEN THAT WE HAVE TO LIVE WITHIN THIS SYSTEM FOR NOW — rang out so loud for me. Because, God help us, we do.

And it is such a reasonable question: Isn’t giving people a heads-up the LEAST you could do? So, Ron asked. On the record.

Ron Lieber: And here’s what they said. Um, they said, yeah, you know, we know more needs to be done here about prior auth, you know, blabbity, blah, blah. And then they said this: ‘We continue to make our own changes to help members navigate through these types of situations, including by offering the opt-in paperless communications.’

Dan: Opt-in. Like — oh, well. You COULDA opted in. Ron was like: Grr. You trying to say it’s my fault, because I didn’t opt in? He says he kept arguing to the United spokesperson — who he says was a total gentleman — you really should just go ahead and give people notice. He says it didn’t take. 

Ron Lieber: So I thought to myself, okay, UnitedHealthcare doesn’t seem that excited to change their processes 180 degrees and do what I’m telling them to do. 

Dan: And by the way, Ron says he has one idea about why they wouldn’t.

Ron Lieber:  If they sent out the kind of notices that I am suggesting, they would need twice as many phone reps and it would cost them a ton of money. And they actually do not want people calling about this. But then I had another idea about how to work around them.

Dan: And that is coming right up.

This episode of An Arm and a Leg is a co-production between Public Road Productions and ���ϳԹ��� News. ���ϳԹ��� News is a nonprofit newsroom covering health issues in America. Their journalists win all kinds of awards, every year. We are honored to work with them.

So Ron has another idea about how — if we have to live in a system where insurance companies issue stupefying, horrifying denials of care to millions of people — we don’t have to get the news at the last possible minute.

And it’s this: Maybe our PROVIDERS could help us out here. I mean, they want to treat us. They want to get paid. We’re a natural team.

So there was an obvious question to ask the folks at Memorial Sloan Kettering: the question he’d held back from pressing on the day of Jodi’s surgery.

That’s when the lady from the billing department told him they’d known about United’s denial for seven or eight days. Why didn’t you give us a heads up?

Ron Lieber: And, um, basically their response went like this, well, we just don’t wanna bother patients with this. We only wanna bother them with, uh, what they described as clinically necessary information. But here’s my response to that, right? Pre-surgery, mental health ought to be part of the institution’s concern, right? You want people walking in there with their heads clear, without too much worry, without too much fear.

Dan: And again: Ron didn’t find himself persuading Memorial Sloan Kettering to change their policy.

So when he wrote all this up in a column — in August, more than eight months after Jodi’s surgery — he basically had a couple pieces of advice for readers. 

One: Yeah, if your insurance requires you to OPT-IN to get a heads-up, then… OK, opt in.

And two: If you need some kind of treatment, ask your doctor’s office some questions: Is prior authorization gonna come into play here? Can you start requesting it ASAP, so we can avoid some last-minute scramble? And if you hit any roadblocks, can someone give me a heads-up right away? And if *I* find out about a problem, who in your office should I call?

That column got people’s attention. More than 500 people left comments. Ron says even for the New York Times, that’s a lot. A lot of them were supportive. A lot were from people who’d had much worse experiences than Jodi and Ron.

Ron Lieber: There were multiple notes from people who said, I was sent home the morning of surgery because they cannot work it out. And there was one person who had already had the anesthesia stuck in her arm and they yanked the needle out and had to send her away to come back and try another day. 

Dan: Oh my God.

Ron Lieber: And then there was like a small handful of readers that were basically like, you’re an idiot, right? How did you not investigate the possibility of an insurance denial ahead of time? 

Dan: He thought about giving that advice in a follow-up column: Never turn your back for a minute. Make multiple calls.

But he decided to take a different approach.

Ron Lieber: And I thought, okay, well how could this have been avoided, um, in our situation? Oh, they could have just given us a very plain spoken piece of paper, you know, upon diagnosis or when we scheduled the surgery.

Dan: Something to give them a heads-up that this kind of thing could happen. In his newsletter, he asked readers for suggestions about what that piece of paper should say.

He says he got lots of responses — including from some angry physicians. 

Ron Lieber: Who said to me, who are you to tell me how to run my medical practice? And then, and this was the loudest one. This is not my fault. Why are you putting this on me? And there were just as many doctors who wrote in who said, hey, in case I miss the story, can you send this to me when it comes out? 

Dan: And he got lots of good suggestions. So he published a column with a template for a note doctors could use.

Ron Lieber: It said: ‘Hey, um, here’s what prior authorization is, and here’s how it works. Um, sometimes people run into problems, um, where the insurance company says that they’re not gonna pay for stuff. We don’t want you to worry about this. You can call us here or email us here if you run into these issues, and we will try to take care of it. If you have any questions about this form, please call our billing specialist. We understand that you don’t want to take up valuable exam time talking about this with the doctor. Frankly, our doctors don’t either, but we wanna make sure that you know about this ahead of time.’

Dan: Again, lots of responses. Useful responses.

Ron Lieber: I got incredibly good critical feedback. And I realized that the note could get a lot better.

Dan: For instance, Ron’s initial memo included some grouching about insurance companies, from a doctor’s point of view. For instance:

“Often, a doctor will have to do what’s known as a peer review with someone from the insurance company. We find this burdensome, since the “peer” on the line with us may not have the same level of expertise as we do. That prolongs the call, adds to our overall operating expenses and keeps us from spending more time with you, the patient.”

And although lots of doctors say exactly those things in lots of forums, they don’t do it on hospital letterhead. 

Ron Lieber: There were some doctors who said, uh, There’s no way I could ever get this by our lawyers. Um, you know, nice try, uh, wish I wish I could, but ain’t gonna happen over here. To which I said, send it to your lawyer and have them call me and we can have a conversation about what would pass muster.

Dan: Other readers told Ron the language just needed to be simpler. They’d his note through software that analyzes a piece of text for reading difficulty. 

Ron Lieber: And then wrote me notes and said, this is written at a 12th grade level. And like, my patients don’t speak English at a first language, or they’re never gonna read this, and you need to write it at a fifth grade level. And so I, so I thought, okay, yeah, that’s, that’s pretty good advice.

Dan: Ron digested all the feedback on the memo he’d published.

Ron Lieber: And then I published another one, which was better, right? It was shorter, the language was plainer. I took out the the commentary.

Dan: We’ll have a link to that second version wherever you’re listening to this. If you’re a health care worker — or know some health care workers who might find it useful — please check it out, pass it around.

Of all the comments on Ron’s stories, one that stuck with me was from a reader who made a wish that was actually like a lament– on behalf of anybody who needed major medical care. Anyone in that situation, they wrote, Quote: “should be enrolled in a certificate course for how to navigate the healthcare system.

Ron Lieber: So this is the thing, Dan, right? This is why I have a job and I’m pretty sure this is why you have a job too. And I would love to be put out of business, right? But the way in which I would be put out of business. Is if there were mandatory certificate programs in 25 different categories of personal finance existence, right. And so that’s how I would be put outta business. But because nobody’s ever gonna require such a certificate in, in any of the areas of personal finance that we are forced, um, to wade through as human beings, I have a job and I’m just trying to do a better job of it.

Dan: ?I hear that. There is so much I appreciate about having my job, but I wish it weren’t so necessary. Lots of people end up in much worse circumstances than Ron Lieber and Jodi Kantor. 

In a book called “Coverage Denied,” coming out this spring, University of Pittsburgh professor Miranda Yaver cites estimates ranging from 850 million to 3 billion denials a year. 

She also cites data showing that appeals work more often than most of us think — about half the time. 

But appealing is hard work. The less privilege you have — like, say if you don’t have a flexible schedule to call and fax and everything else — the harder it is.

She calls the result “Rationing by inconvenience.”  

And we can all use all the help we can get making life less annoying and inconvenient. Which is why I’m gonna leave you with Ron Lieber’s answer to my last big question for him. 

Because hearing  one part of his advice on how not to get blindsided by an insurance denial led to another question — one that seemed like a good one to ask an expert at beating the system. 

I said:  Hey, you recommend opting in to emails and texts from your insurance company so they might give you a quicker heads-up. 

Let’s say I do. How the heck am I supposed to find that in my inbox — which keeps getting harder to sort through every day with things I don’t want and don’t need to look at? 

I asked him: How do you, Ron Lieber, manage the inbound?  How do you identify what actually needs your attention?

And he had a good answer:

Ron Lieber: ?Yeah. So I have three email inboxes. I have, you know, work email, I have personal email that is only personal correspondence and the most vital other stuff, you know, kids’ school, uh, college tuition payments. And then I have an old Yahoo email for everything else. And so, you know, I read the last 12 to 24 hours of the Yahoo email, you know, once a day or so. Uh, and then, you know, once a month, I’ll open the inbox and I won’t close it until I’ve unsubscribed to 10 things. And, and so that keeps it more or less manageable.

Dan: This is such good advice. I haven’t had a chance to implement it since I talked with Ron — hey, I was on deadline for this episode! — but honest:  I’m going to. 

Here’s one other thing I’m going to do in the next few weeks:  Have surgery myself. A hernia repair, it’s gonna be fine, I’m in great hands.  But it’s happening a few days before our next episode is scheduled to come out.

So, as it happens, I’ve got a great story from somebody ELSE to share with you then. We’ll have another new episode of our own for you when I’m back.

And meanwhile, we’ll keep the First Aid Kit newsletter coming. If you aren’t subscribed, it’s really good! 

My colleagues Emily and Claire have been serving up need-to-know information:  Like, when you get your annual checkup… what’s actually covered?  A lot of the time, it’s less than you’d think.

Which sucks, but is SO important to know. If you’re not signed up, check it out at arm and a leg show dot com, slash, newsletter.

I’ll catch you soon. Till then, take care of yourself.

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with ���ϳԹ��� News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at ���ϳԹ��� News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.