Mrs. Berger never intended to work in the health insurance field, much less to become the leading expert in the tristate area — relied upon by patients, doctors, hospitals, and HMOs for advice and solutions. It happened at the conclusion of an interview for a position with a large nursing home in Lakewood, a position that turned out not to be the fit she was looking for. Yet as she was leaving, the interviewer tossed out, “Wait. We were thinking about hiring someone to handle our insurance negotiations in-house. Would you be interested in that role?”

She agreed, and spent the next year and a half learning every detail of health insurance contract negotiations and the many issues nursing homes face. She soon became established in the industry, gaining name recognition and an extensive network of contacts. Others began asking for her help with their provider contracts; the two nursing homes she worked with quickly grew to eight, and then the field exploded. The expanding volume of requests eventually led her to set up an independent company, INC Solutions, that serves as a liaison service between medical providers of all types and health insurance companies. Today, INC Solutions has a national presence, servicing hundreds of providers and companies across the United States.

“Your doctor’s office faces the same frustrations you do,” she explains about the business. “They have to cut a contract with an insurance company in order to be part of their network. Often, doctors can find their treatments held up and delayed by paperwork. They don’t want to schedule a ten-hour surgery and come to work to find that it has been canceled over a missing document. Other times, they can struggle to get paid — going months to years without getting reimbursed by insurance because of an administrative issue.”

Concurrently, with the growth of her business, opportunities for a unique form of chesed blossomed as well. With thorough knowledge and contacts in an arena that is largely untapped and immensely complicated, Mrs. Berger found herself in a highly specialized position from which she could help people in a way that has a significant impact on their lives.

“In six years of doing this, working on thousands of cases, I’ve seen that most true needs are resolvable,” Mrs. Berger says encouragingly. “As long as there is a legitimate medical professional standing behind them, these requests can generally be resolved satisfactorily.”

While the business end has been quite successful, Mrs. Berger doesn’t charge individuals for her help. More than one industry CEO has told her, “Shuli, I don’t understand — you have a business. Why are you doing this for free?”

“When you have something to give and Hashem puts you in a position to help, then it obligates us to step up to the plate,” she says in response. In fact, the chesed aspect of her work has actually broadened her reach. She spends a large portion of her time building relationships with executives, and when leaders of the industry see that she gives her assistance away for free to those in desperate need, it garners a newfound respect.

Today, from her position as adviser and problem-solver to the three distinct stakeholders — patients, providers, and insurers — Mrs. Berger has a more nuanced view of the problems plaguing America’s healthcare system. And while she doesn’t have one single neat solution, she offers hope — and concrete suggestions — for improvement at every level, and among all three players in the healthcare triangle.

Take It to the Top

Last December, headlines around the US reported the murder in cold blood of Brian Thompson, a top insurance executive gunned down on his way to a corporate meeting in Manhattan. Many wondered what motive there could be for executing an insurance CEO, but as the case took shape, the horror only increased. The prime suspect, a young man named Luigi Mangione, had experienced frustration with his medical insurance while dealing with a back injury. Thompson was the CEO of United Healthcare, and Mangione allegedly targeted him as a representative of the entire industry.

But the true shock was still to come: In the wake of Mangione’s arrest, an outpouring of approval and an identification with his frustration became apparent on some level of the American consciousness. People began posting messages of support for the murderer on social media. A sweater he was seen wearing sold out quickly online. Supporters even contributed to fundraising campaigns for his defense — over $300,000 has been collected to date.

The episode revealed a skewed morality among a disturbing number of Americans, but it also drew attention to a subject all too familiar: the healthcare bind.

Few concerns in modern adult life are as bewildering — and as consequential — as navigating the world of health insurance. Inadequate coverage can literally spell the difference between life and death during a medical crisis, yet overly expensive policies can break the budget of a family struggling to cover costs.

Frustrations run high. With moderate family plans hovering around $3,000 per month, and premium plans climbing to nearly $6,000 monthly, the average American family can easily spend more on medical insurance than on their mortgage or any other ongoing expense. Yet when visiting the doctor, dentist, or dealing with a medical crisis, they are often still hit with a big bill and an explanation couched in a list of indecipherable technical terms — deductible, denial, copay, coinsurance, authorization, network, provider contract, and more.

“You don’t have to be an expert to see that healthcare in the United States is a mess,” Mrs. Berger says. But in a departure from the popular perception, she doesn’t blame health insurance companies as avaricious, cut-throat businesses actively seeking to deny care to desperate patients.

“Generally speaking, CEOs of large insurance companies don’t wake up thinking, ‘Today I’m going to generate large revenue by indiscriminately rejecting claims and services.’ In any large volume, there is going to be fallout, and my goal is to work out those cases that come to me. I’ve found that the vast majority of executives are very human, reasonable, and willing to have a conversation. Insurance companies don’t grow their revenue by not giving good service.”

Mrs. Berger has found that company heads will actually engage deeply with the community, and will often display dedication, working beyond the call of duty to help their members.

“More than once,” she says, “I’ve had a CEO call me on a holiday weekend, or ten o’clock at night. Sometimes, it’s ‘Shuli, I just noticed there’s a surgery scheduled for tomorrow at a certain hospital and it’s going to cancel because they’re missing a code. Can you call their doctor and make sure it’s put in so we can approve it?’ And sometimes it’s about them calling the head of a hospital to guarantee payment for an expensive procedure that the hospital’s financial team is hesitant to allow because they’re not used to working with that insurance company.”

Mrs. Berger relates that murder victim Brian Thompson — the target of a deranged man’s wrath and whose contact information is still saved in her phone — was always working quietly and selflessly to help his members.

“There could not have been a less fitting target of anti-insurance company ire,” she says. “Brian Thompson was a very approachable mid-western father of two. He helped proactively and often, and always demurred taking credit. He put many policies in place to mitigate frustrations people face. He was a far cry from the image of an untouchable ivory tower elite. In fact, at the time of his murder, I had a draft email written out to him to have him help out with an issue we were facing for a Lakewood child who needed services that kept getting denied.”

If insurance execs are such saints, why do people feel like they’re scaling an iceberg when they try to get somewhere with their carrier?

Part of the answer is logistical. Like any other large corporation, insurance companies have a rigid structure. All requests for nonstandard care begin with an authorization request submitted by the treating physician. These go into a queue along with thousands of other requests the company receives daily, where it is picked up by a nurse case manager, who will either approve it or refer it to a medical director for a more complex decision that is then returned to the doctor.

The executives — the ones with both the heart to feel a patient’s pain and the authority to waive a rigid rule — are out-of-reach of most consumers. But that doesn’t mean they can’t be accessed.

“You can keep elevating a concern until you get someone who can listen and understand,” Mrs. Berger says. “Often, I will send in a picture of a child along with an authorization request, just to remind the processor that this is a real person, with feelings, friends, and family.”

Not only don’t the low-level reps have the authority to cut red tape, they often don’t understand the full factors of a case. For example, Mrs. Berger worked to help a patient who had a heart condition and therefore couldn’t tolerate standard local anesthesia. So when he needed a root canal, it meant he had to go to a child specialist center where he could receive cardiac-sensitive anesthesia. But the processor just saw “root canal at children’s hospital” and denied the request.

There is a simple appeals process for denials, which many patients and doctors don’t know about and do not utilize. The denial letter will have a number one can call to make a verbal appeal, which consists of a simple explanation of the details of the case and why it should be an exception to policy.

“Even before that step,” Mrs. Berger clarifies, “there is also opportunity for their doctor to schedule a call to speak with the overseeing physician in the insurance company that has the ability to overturn a denial. Many denials are overturned at that point, and that piece of the process should really be used as a first step. If that’s rejected, petitioners should know that two rejections are often standard before an approval — it’s almost an unwritten rule. However, after the internal appeals process that works within the insurance company review, there is a state-level appeal, and I’ve seen a lot of success with minimal effort on that level.”

In case of further denial, a written appeal can be submitted. It can take up to 30  days to be addressed, but there’s another little-known tip here. A written appeal tagged as “urgent” or “expedited review” will get a response within 72 hours.

“I highly encourage people to add that tag where appropriate,” she says. “It doesn’t have to be a life-and-death emergency — anything that cannot wait 30 days legitimately qualifies for expedited review. It can be anything that will have some kind of negative health impact if not immediately addressed, or even an open appointment at a specialist that will be missed.”

Who’s to Blame?

Beyond the actual process of applying for coverage, there are many players in the complex healthcare web. And, Mrs. Berger says, they all carry some share of responsibility. Insurance companies, hospitals, doctors, pharmaceutical companies, state and federal leaders and agencies, and even voters, are all part of the mix.

It’s a gut response to blame an insurance company when a procedure, doctor’s appointment, or medication is denied. But often, the problem is rooted elsewhere. It could be, for example, in the office of the provider who didn’t know how to put the request in, it could be with the patient who withheld insurance information, or it could be with a state agency that suddenly terminated a policy.

“Insurance companies are trying to manage their business within the state regulations they are bound to honor,” Mrs. Berger explains. “States make rules within their jurisdiction, subject to restrictive federal legislation [such as Affordable Care Act, a.k.a. Obamacare]. And some mandated services also drain a lot from these companies, pushing up premiums. Limiting insurance companies within states has a huge impact on the market, stifling competition that would drive prices down.”

States also require insurance companies to have a minimum number of specialists of each type in-network. But some of those specialists don’t exist. Insurers in New Jersey, for example, have been complaining that they’re getting fined for lacking providers that simply can’t be found in the state.

All these issues can cause frustration to clients — but aren’t directly the fault of the insurance companies.

That’s not to say that insurance companies always get it right. Mrs. Berger has seen a fair share of irrational denials, from an adult suffering from traumatic brain injury being denied rehabilitation, to a child needing second-stage cardiac surgery suddenly getting a no.

In some cases, though, the problem lies with hospitals, which can sink many referrals or transfers. This can be caused by any or all of institutional hubris, overregulation, incompetence, or just plain greed.

She mentions a recent case in which a hospitalized child coded and had to be transferred from the local facility to a specialty pediatric hospital that was equipped to service him and save his life. But the receiving hospital refused to take the child without authorization, yet the local hospital refused to ask for authorization.

“After receiving a desperate call from the parents,” she relates, “I called the insurance company, and as soon as the insurance manager looked at the clinical details and saw the condition was critical, he overrode the internal system, made an authorization without a request, gave it to both hospitals, and the child was transferred less than an hour later.”

The insurance companies are often fingered as the bad guys, but sometimes, it’s the hospital that is unwilling to admit that it cannot service the patient. This can be to protect their reputation or even to avoid acknowledging that they don’t have enough specialists on staff, which can make then liable for state penalties or pushback on their insurance contracts. Mrs. Berger still remembers this story, an unfortunate case in point:

Red and blue lights cut the darkness. Emergency vehicles surrounded a stalled minivan, crushed against an unforgiving tree. Inside an ambulance, as sirens screamed through the night, medics treated a young child.

“He’s going to survive,” the attending emergency-room physician told family members, “but his skull and part of the face were crushed. He’ll need extensive plastic and cosmetic reconstruction. Don’t worry, we have a cranial-facial surgeon right here in-house.”

The hospital, however, did not have a surgeon in-house. There was one cranial-facial plastic surgeon on staff, but she was on maternity leave for the next four weeks. Still, the hospital, out of fear of incurring penalties, refused to release the patient to another facility, insisting they could handle the procedure.

In the end, after Mrs. Berger called her insurance contacts and made it clear that there was no surgeon available, the transfer went through.

Sometimes it happens that a particular hospital doesn’t deal often enough with a certain insurance carrier or type of procedure, and simply doesn’t know how to request an authorization. And at times, the sending hospital will sabotage the approval, because it doesn’t want to relinquish the revenue it would gain by keeping the patient.

And sometimes the doctors themselves can do things differently to avoid problems.

“Too many doctors’ offices don’t submit claims or set up their internal system properly,” Mrs. Berger relates. “Sometimes the doctor’s office doesn’t understand how to set up the system, and sometimes they just can’t be bothered. Patients can wind up spending thousands of dollars in out-of-pocket costs on specialists, because the physician doesn’t want the headache of working through an approval process.”

How can doctors’ offices better streamline the process? “When a doctor’s office is set up correctly, many of the problems and frustrations can be resolved or prevented. This includes making sure that their ability to take insurance is set up properly from the get-go, how to request authorization from an insurance company, and the ability to request out-of-network services for patients,” she explains.

Mrs. Berger has seen large hospitals and high-level doctors go unpaid by insurance for over a year, and even drop working with the insurance company for lack of payment, when all that was involved was a billing mix-up that could have been avoided.

Sometimes, though, it’s the policy itself that just doesn’t have enough coverage. Better understanding of a policy before purchasing can often prevent the issue.

But for many people, that’s no simple task.

“So many people don’t understand the basic terms of health insurance, which is often one of their biggest expenses and can be a critical, life-altering resource,” Mrs. Berger says. “The more people can understand the way their insurance works, what it covers, and what expenses they should expect in case of a medical need, the easier that journey will be. It’s worth taking time to research insurance options before finalizing a decision.

“And when choosing,” she continues, “keep in mind that insurance is not intended for the regular strep tests and ear infection checks. Don’t get hung up on the small extras, like gift cards for enrollees. Those things are nice, but have minimal long-term benefits. Insurance needs to be good enough to cover the bigger expenses at a reasonable level.

“Many people pick something cheap and daven that they shouldn’t need more. But they need to understand the risks involved. Currently, understanding the options is out of reach for too many people. It’s on the community to raise the level of education. In fact, much of what I do when I field calls from frustrated parents is explaining to them how the system works and what to expect.”

Know Your Customers

The Orthodox Jewish communities in New York and New Jersey, particularly in Lakewood and the environs, are a rarity for the insurance companies. These communities are a potential gold mine for health insurance. They are flush with large, young families that pay conscientiously and avoid many of the unhealthy or decadent societal habits that cost insurers steeply.

“We have very high rates of preventative medicine, such as well-visits, vaccinations, and lead testing. Insurance companies even make money off maternity patients, which earns them bonuses,” Mrs. Berger avers.

On the flip side, there are close to 80,000 children in Lakewood. Statistically, this means there will be a higher regional concentration of rare childhood diseases and developmental conditions. Those that take the time to get to know the community understand and appreciate the importance of providing access to specialists.

According to Mrs. Berger, the successful companies continually take the time to understand, get to know, and develop relationships within the community. Through her work, she’s developed a relationship with c-suite executives and partners on all levels of every insurance company in the tristate area and throughout the country. Today, many of these insurers consult her for advice on recruiting and retaining membership, or policy rules that affects the frum community. Her guidance has helped companies accomplish dramatic turn-arounds.

For example, a large majority of the Lakewood community shifted from one HMO to another in 2018, and back to the first in 2022. A significant move is underway again. These shifts are caused, in a large part, by the adaptability of company policy to the community’s unique needs. Mrs. Berger’s guidance was key in helping corporate execs understand the impact of their rules and coverages; those who followed her suggestions were able to collaborate with the community and reap the benefits.

When executives are invested, they also get to know key doctors in the town and understand communal needs. The invested execs can learn things about the community that inform policy and procedural changes. For example, many companies send alerts and updates via text message. In Lakewood, that might not work for many subscribers who don’t have text capabilities on their phones. Insurers recently added a postpartum convalescent facility to their benefits in Lakewood.

When CEOs visit Lakewood, Mrs. Berger’s team shows them, among other things, the medical chesed organizations that cover the town.

“They are stunned at the world of chesed,” she says. “They can’t wrap their brains around what Hatzolah, Chai Lifeline, and others do.”

Visiting Bikur Cholim’s massive warehouse, filled with thousands of pieces of medical equipment available for free loan, one insurance CEO broke down and cried. “I didn’t know this level of humanity still existed in this world,” he said.

Another CEO, visiting Tomche Shabbos’s warehouse, had grown up on welfare, and when he saw the enormous amount of food earmarked for distribution, he said, “I can only imagine how different my life would be, had this been available in my community when I was a child.”

But the in-person meetings aren’t just meant to impress or inspire. They also result in tangible gains for both the insurers and the insured.

One CEO turned over his company’s market position from worst to best in a few months. When asked how he did it, he said simply, “I did my day job at night.” He spent his days traveling to communities, meeting people and adjusting policies, such as adding patient advocates, assigning case managers, changing case management systems, and cutting contracts with specialists that are needed, even though they might not be so lucrative.

On the flip side, Mrs. Berger was recently consulted on a rash of request denials from a particular insurer. She called the CEO. “Your company is failing here,” she told him. “If you don’t do something quickly, your membership will be almost nonexistent, and perhaps permanently.”

“What are we doing wrong?”

“I’ve seen five denials in the last three days that make no sense. Patients aren’t getting what they want, and the top doctors in town are frustrated with you and want to drop your company.”

“I don’t understand — all those denials were for out-of-network providers! Other insurance companies would have covered it?”

“You don’t have these services within 60 miles. Yes, had these patients been members of any other HMO, they would not have been denied.”

“What are those companies doing that we’re not?”

“To be honest, their CEOs are constantly here to visit and understand the local needs. I haven’t seen you in two years.”

“Okay, I’ll pay you a visit.”

“Great. But make sure you bring your medical decision-makers along and are prepared to make real policy changes.”

“It took a few days to schedule that meeting,” Mrs. Berger says, “and we brought in some of the doctors when they came in so they could understand what wasn’t working first-hand. Since that meeting, policy change conversations are starting to happen.”

If there’s anything Mrs. Berger has learned from her years of advocacy, it’s how the human factor can cut through even the most complex bureaucratic barrier. Over and over, she’s seen the importance of community, cooperation, connection, and conversation; how a strong foundation of trust solves problems and opens doors.

“It’s not uncommon for a CEO to tell me, ‘Shuli, I don’t understand why this transfer or appointment is important, but if that doctor you introduced me to says it is, we’ll authorize it.’”

In July 2024, a meeting was initiated with New Jersey state legislators to advocate for legislation that would simplify the regulations and expand access to care.

The lawmakers agreed that the insurance structure is a huge problem — but no one had a plan to fix it. “Shuli, we can sooner fund advocates like your company to help people navigate the ball of yarn, than find solutions to the mess,” they told Mrs. Berger.

The bottom line? “The system is hugely raveled chaos and it is not going to change any time soon,” Mrs. Berger says. “So in the meantime, we need to learn to navigate it, and make it work for us.”

Terms of Agreement

Some explanations to help you better understand what’s happening with your policy

Provider Network: The list of health care providers that are contracted with an insurance company to provide care to the members of that insurance company.

Premium: The amount a person pays for health insurance every month.

Deductible: The amount paid out of pocket for covered health services before the insurance pays.

Copay: A fixed amount the patient pays the provider before receiving the service.

Coinsurance: The percentage of costs of a covered health care service paid (often after deductible).

Max Out of Pocket: The most a patient will pay for covered services in a year (includes deductible, copay, and coinsurance).

Prior Authorization: An approval required before certain services/medications are given.

Emergency: In situations involving reasonable risk to life, insurance authorizations are not needed. The best care for the patient is the only legitimate factor, and insurance must legally pay.

Urgent Request: Providers can flag an authorization request as “Urgent,” which will push it to the top of the processing queue. Such requests are triaged based on when treatment is needed. In most cases, a decision must be issued within 72 hours. This is appropriate in any scenario where patient care will suffer/be delayed if it takes the standard 14 to 30-day turnaround.

Network Sufficiency: By regulation, insurance networks must include reasonable access to specialists. For example, in New Jersey, it must offer a choice of at least three specialists within 45 miles or a maximum 60-minute drive, with an appointment available within 30 days/reasonable amount of time when needed. If any of these factors are not available in-network, the company must approve an out-of-network provider, even a specialized facility in another state. This is how coverage can be achieved for New Jersey residents to get care at prime destinations, such as New York City hospitals, Children’s Hospital of Philadelphia (CHOP), Cincinnati, Cleveland Clinic, and more.

Appeals: There is an appeals process for every denial, and that is outlined in the denial letters many throw away. This is very important and even part of the unwritten system.

IURO Appeal: This is the state-level appeal available in most cases of denials. Once the internal level of appeals is complete, the patient has an ability to write an appeal, outline the situation and provide supporting documents to an independent company. This Independent Utilization Review Organization is contracted by the state to review insurance denials at the request, and for the benefit, of the member, when the member feels an incorrect denial was given. Most appeals at this level get approved. This part of the process is a very worthwhile one to follow.

Denial Evidence: Always save denial letters. They have the information needed to be referenced when help is needed.

Medical Complexities: Families that have known medical issues would be very unwise to choose the cheapest plan, as it can be a very costly mistake. Still, expensive doesn’t always mean better. Take the time with your broker to go through the coverage of the plan in relation to your needs.

Out of State: Many insurance plans do not cover treatment in other states. Unless you have employer-provided insurance for an interstate company, this is not likely to be provided. However, this doesn’t mean there’s no possibility of coverage. The fair rule is that when the treating provider believes it’s medically appropriate, there is usually a legitimate way to get the treatment covered, but it starts with an authorization request. Follow through the appeals process, and usually it will work when done properly.

—Rachel Ginsberg contributed to this report.

(Originally featured in Mishpacha, Issue 1059)