Surgeon’s Experience Highlights Insurance Challenges

In January, Dr. Elizabeth Potter found herself in a rather unusual situation during breast reconstruction surgery. A representative from UnitedHealthcare called the operating room to discuss patients currently under her care.

“United Healthcare wanted to talk to me immediately,” Potter recounted in an interview with NBC News. She later shared a TikTok video of the experience, which attracted nearly six million views.

During that call, a UnitedHealthcare representative requested further details about why certain patients required overnight hospitalization, despite the fact that their surgeries had already been authorized.

“The person on the other end even asked for a diagnosis of a patient who was already anesthetized,” Potter explained. “It was quite alarming. If they can interrupt my surgery to ask me to justify a patient’s overnight stay, we’ve really lost our sense of direction in healthcare.”

Potter acknowledged that she chose to step away from surgery to take the call. However, she expressed concern about the power such insurance companies hold, remarking, “If insurance can dictate my actions like that, what does that mean for my practice?”

A spokesperson from UnitedHealthcare clarified that the company didn’t expect physicians to pause patient care for such inquiries.

Potter claimed that UnitedHealthcare refused to cover the cost of hospitalization, stating that while the stay had been authorized, a mistake occurred in another related request.

Feeling targeted by the insurance company for her social media posts, Potter is concerned about her clinic, Redbud Surgery Center in Austin, Texas, facing potential bankruptcy. She established this clinic in April 2024, but stated that UnitedHealthcare has not allowed it to join their provider network, even though she remains within the network as a surgeon. This situation complicates her ability to perform surgeries at a hospital, as the facility isn’t covered under the network.

The network system means that if a healthcare provider has a contract with an insurance company, certain services are paid at a pre-established fee. If a provider is out-of-network, patients often bear the cost themselves if insurance denies coverage.

With the inability to accept UnitedHealthcare patients, Potter fears her clinic may not survive. Although she is exploring partnerships with other insurers, UnitedHealthcare is a major player in Texas, making this particularly difficult.

Currently, she is facing a debt of $5 million, and her husband had to cash out his 401(k) to keep them afloat.

“I always ask myself how to make this work; I like solving problems,” she shared. “But it seems arbitrary and a bit harsh that they control the economic aspects of my medical practice.”

A spokesperson for UnitedHealthcare stated that they notified Potter in October 2024 about the closure of the network to the new center well before she started sharing videos online, suggesting that her clinic was redundant due to enough surgical centers already present in the area.

They also mentioned that Potter’s consultants reached out post-October, but indicated that no negotiations were active.

Potter disagrees, asserting that there were still ongoing discussions encouraging her to join the network until January.

Underlying Tensions

Experts believe Potter’s predicament is emblematic of ongoing conflicts between healthcare providers and insurance companies. Dr. Adam Gaffney, an assistant professor of medicine at Harvard, highlighted that navigating relationships with health insurers is a common challenge for physicians across the United States. While insurers work to manage costs by preventing unnecessary care, this often translates to burdensome hurdles for doctors trying to provide timely patient care, sometimes even after services have been rendered.

Despite being in-network, research has shown that insurance companies deny an average of 17% of claims even for covered doctors. “This isn’t why many people become doctors,” Gaffney remarked.

Recent events have also cast a spotlight on the challenges faced by patients and providers with health insurance. The departure of United Health Group’s CEO, Andrew Witty, amid public scrutiny following a tragic incident has only intensified attention on the company’s practices.

As discussions about healthcare systems continue, Dr. Arthur Kaplan, from NYU Langone Medical Center, argues that the profit-driven nature of the insurance system is morally questionable. He emphasized the need for substantial government intervention to address these systemic issues.

Looking Ahead

Dr. Potter expressed a belief that the healthcare system needs reform, but maintains that insurance, when functioning correctly, serves to make care more accessible for patients.

Since leaving her hospital position and starting her own clinic, Potter aims to provide necessary surgeries to women in a safe and effective manner. She remarked that to ensure safety and compliance, substantial hurdles exist in the process of opening surgical centers.

Despite her best efforts, she is currently without a salary and worried that she may have only a few months left in the business. “I want patients who are medically appropriate waiting at my center for surgery. This is why I keep my doors open,” she stated. “I simply want to take care of them.”