A clinic visit found a tick with Lyme, but her insurer wouldn't pay

Leah Kovitch was pulling invasive plants in the meadow near her home one weekend in late April when a tick latched onto her leg.

She did not notice the tiny bug until Monday, when her calf muscle began to feel sore. She made an appointment that morning with a telehealth doctor - one recommended by her health insurance plan - who prescribed a 10-day course of doxycycline to prevent Lyme disease and strongly suggested she see a doctor in person. So, later that day, she went to a walk-in clinic near her home in Brunswick, Maine.

It's a good thing she did. Clinic staffers found another tick on her body during the same visit. Not only that, one of the ticks tested positive for Lyme, a bacterial infection that if untreated can cause serious conditions affecting the nervous system, heart and joints. Clinicians prescribed a stronger, single dose of the prescription medication.

"I could have gotten really ill," Kovitch said.

But Kovitch's insurer denied coverage for the walk-in visit. The reason? She had not obtained a referral or preapproval. "Your plan doesn't cover this type of care without it, so we denied this charge," a document from her insurance company explained.

Health insurers have long argued that prior authorization - when health plans require approval from an insurer before someone receives treatment - reduces waste and fraud, as well as potential harm to patients. And while insurance denials are often associated with high-cost care, such as cancer treatment, Kovitch's tiny tick bite exposes how prior authorization policies can apply to treatments that are considered inexpensive and medically necessary.

Pledging to fix the process

The Trump administration announced this summer that dozens of private health insurers agreed to make sweeping changes to the prior authorization process. The pledge includes releasing certain medical services from prior authorization requirements altogether. Insurers also agreed to extend a grace period to patients who switch health plans, so they would not immediately encounter new preapproval rules that disrupt ongoing treatment.

Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, said during a June news conference that some changes would be in place by January. But so far, the federal government has offered few specifics about which diagnostic codes tagged to medical services for billing purposes will be exempt from prior authorization - or how private companies will be held accountable. It is not clear whether Lyme disease cases like Kovitch's would be exempt from pre-authorization.

Chris Bond, a spokesperson for AHIP, the health insurance industry's main trade group, said that insurers have committed to implementing some changes by Jan. 1. Other parts of the pledge will take longer. For example, insurers agreed to answer 80 percent of prior authorization approvals in "real time," but not until 2027.

Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, told KFF Health News that the changes promised by private insurers are intended to "cut red tape, accelerate care decisions, and encourage transparency," but they will "take time to achieve their full effect."

Meanwhile, some health policy experts are skeptical that private insurers will make good on the pledge. This is not the first time major health insurers have vowed to reform prior authorization.

Bobby Mukkamala, president of the American Medical Association, wrote in July that the promises made by health insurers in June to fix the system are "nearly identical" to those the insurance industry put forth in 2018.

"I think this is a scam," said Neal Shah, author of the book "Insured to Death: How Health Insurance Screws Over Americans - And How We Take It Back."

Insurers signed on to Trump's pledge to ease public pressure, Shah said. Collective outrage directed at insurance companies was particularly intense following the killing of UnitedHealthcare CEO Brian Thompson in December. Oz specifically said that the pledge by health insurers was made in response to "violence in the streets."

Shah, for one, does not believe companies will follow through in a meaningful way.

"The denials problem is getting worse," said Shah, who co-founded Counterforce Health, a company that helps patients appeal insurance denials by using artificial intelligence. "There's no accountability."

Cracking the case

Kovitch's bill for her clinic appointment was $238, and she paid for it out-of-pocket after learning that her insurance company, Anthem, didn't plan to cover a cent. First, she tried appealing the denial. She even obtained a retroactive referral from her primary care doctor supporting the necessity of the clinic visit.

It didn't work. Anthem again denied coverage for the visit. When Kovitch called to learn why, she said she was left with the impression that the Anthem representative she spoke to could not figure it out.

"It was like over their heads or something," Kovitch said. "This was all they would say, over and over again, that it lacked prior authorization."

Jim Turner, a spokesperson for Anthem, later attributed Kovitch's denials to "a billing error" made by MaineHealth, the health system that operates the walk-in clinic where she sought care. MaineHealth's error "resulted in the claim being processed as a specialist visit instead of a walk-in center/urgent care visit," Turner told KFF Health News.

He did not provide documentation demonstrating how the billing error occurred. Medical records supplied by Kovitch show MaineHealth coded her walk-in visit as "tick bite of left lower leg, initial encounter," and it is not clear why Anthem interpreted that as a specialist visit.

After KFF Health News contacted Anthem with questions about Kovitch's bill, Turner said that the company "should have identified the billing error sooner in the process than we did and we apologize for the confusion this caused Ms. Kovitch."

Caroline Cornish, a spokesperson for MaineHealth, said this is not the only time Anthem has denied coverage for patients seeking walk-in or urgent care at MaineHealth. She said Anthem's processing rules are sometimes misapplied to walk-in visits, leading to "inappropriate denials."

She said these visits should not require prior authorization and Kovitch's case illustrates how insurance companies often use administrative denials as a first response.

"MaineHealth believes insurers should focus on paying for the care their members need, rather than creating obstacles that delay coverage and risk discouraging patients from seeking care," she said. "The system is too often tilted against the very people it is meant to serve."

Meanwhile, in October, Anthem sent Kovitch an updated explanation of benefits showing that a combination of insurance company payments and discounts would cover the entire cost of the appointment. She said a company representative called her and apologized.

In early November, she received her $238 refund.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF - the independent source for health policy research, polling and journalism.