ILWU Workers and Providers Struggle Amid Payment Delays and Rising Costs
By Terelle Jerricks, Managing Editor
Insurance rates, whether for vehicles, fire insurance, earthquakes, floods, or human health, have gone up for all of them, but without necessarily providing the equivalent increase in coverage. The consequences are denied claims in moments of crisis, as was the case with the Pacific Palisades and Altadena fires during a moment when fire insurance providers have been leaving the California market and homeowners in the lurch.
In the case of the health insurance market, even employer-provided insurance is not immune to the vagaries of the wild insurance market.
The ILWU Coastwise plan, long considered the gold standard when it comes to health insurance, is showing strain as health providers who cover workers on the waterfront go out of business waiting to be paid because of claim denials.
One of those businesses that are on the precipice is Marina Sports Medicine, operated by Tim Ursich Jr. Founded more than 35 years ago by his father of the same name, the practice provides chiropractic, physical and massage therapy, and diagnostic services. The majority of his patients are longshore workers.
A few months back, Ursich showed RLn a banker’s box full of unpaid claims going back to October 2022. The current Longshore contract started in July 2022. With more than 2,000 denied claims, Ursich says the new third-party administrator Innovative Care Management (ICM) has disallowed more than $200,000 worth of claims.
Ursich noted that about 70% of his clients are longshore workers — something he acknowledges as a problem from a business standpoint, to be so reliant on a single demographic.
“You have to treat who comes in right? I’m a second generation [longshore working family] coming in treating who’s coming in. Because my dad grew up [in this town and worked on the waterfront] everybody in his life is a longshoreman … they congregate,” Ursich said. “I’d be the first one to tell you it doesn’t feel like you’re at a doctor’s office when you’re in our office. It’s like a reunion. We’re talking about everything that’s happening under the hook … [including] about somebody who got hurt during the night.”
However, the issues that Ursich and his clients are facing are partly similar to what others are facing, while others are specific to what’s happening with the ILWU. The issues relating to the ILWU are due to too many union members retiring or dying off without sufficiently passing on institutional knowledge as it relates to the ILWU Coastwise contract.
ProPublica Bombshell
About a week before Ursich spoke to Random Lengths about ICM, ProPublica published the findings of their joint investigation with Capitol Forum. In that story, ProPublica revealed how health insurers outsource prior authorization reviews to companies like EviCore, which profit by denying medical claims. EviCore, owned by the insurance giant Cigna, provides coverage to about a third of insured Americans. It employs an AI-driven algorithm, nicknamed “the dial,” to flag claims for review and adjust thresholds to increase denial rates. While EviCore claims to ensure safety and cost-effectiveness, critics, including medical professionals, argue that its guidelines often delay or deny necessary care. Contracts with insurers incentivize cost-cutting, making EviCore’s profit-driven practices a point of contention.
The investigation details how EviCore leverages its algorithm to maximize cost savings for insurers. The algorithm scores claims based on their likelihood of approval and adjusts the threshold to escalate reviews, increasing the chance of denials. Former employees have disclosed that this practice allows EviCore to manipulate outcomes to meet financial goals. Frustration among doctors over rigid and outdated guidelines has even led to mockery of the company online. Despite EviCore’s claims that its decisions are guided by evidence-based practices, the investigation found that internal policies often prioritize savings over patient care.
But the ProPublica investigation found that EviCore is not alone in this “denials-for-dollars” business; other companies like Carelon Medical Benefits Management also engage in similar practices. While prior authorizations are essential to prevent unnecessary treatments and fraudulent billing, the investigation raises concerns about the industry’s impact on patient care. EviCore defends its operations, emphasizing patient safety, cost reduction and adherence to medical guidelines. However, the findings suggest a systemic issue where financial incentives overshadow the healthcare needs of individuals, prompting calls for greater oversight and reform.
ProPublica detailed the experience of a 61-year-old former welder from Ohio, who, in 2021, began experiencing alarming heart symptoms. His doctor recommended a left heart catheter examination to check for blocked arteries, but the procedure was denied twice by his insurer, UnitedHealthcare, after consulting EviCore, a company specializing in prior authorization reviews. The denials left Cupp and his doctor with limited options, exemplifying the frustration many patients face in navigating healthcare decisions influenced by profit-driven insurers and third-party reviewers.
Critics argue that EviCore’s business model encourages excessive denials and undermines objective evaluations of medical requests. Former employees reveal that algorithms can be adjusted to increase or decrease approvals based on client demands or internal goals, leading to inconsistent outcomes. Experts and industry insiders question whether such practices meet legal and ethical standards, calling for greater transparency and accountability in the relationship between insurers, third-party reviewers, and patients. The case of Cupp underscores the human cost of a system that often prioritizes financial gains over timely medical care.
Lack of Transparency
As part of the ILWU benefit package, the Pacific Maritime Association pays $480 million on health care annually. During the last contract talks, the union replaced the third-party administrator EviCore with ICM.
A former ILWU Local 13 Safety and Benefits Officer Dave Beeman explained that during contract negotiations the change to ICM was made.
He noted that in contract negotiations, maintenance of benefits is the first issue that’s actively arbitrated until the union is satisfied. Until maintenance of benefits is achieved, no other portions of the contract can be negotiated.
“One of the problems that we had in these last negotiations was that it took so long for the company and the plan to agree to the terms that were put on the table by the union for the maintenance of benefits,” Beeman explained. “Once they claimed to have met the demand of maintenance of benefits, contract negotiations resumed and ultimately concluded during that period of contract negotiations. When that change was made, it violated the terms of maintenance of benefits because it is not maintenance of benefits to remove one provider and install another one.”
Beeman said that the bottom line is that the trustees failed the membership on this issue.
“I don’t know anybody that has the balls to stand up and say it in front of a group of people. I have nothing to lose. I’m retired,” Beeman said.
In the end, Ursich’s Marina Sports Medicine still hasn’t been paid after repeated attempts to appeal the denials and the ILWU leadership has been moot on responding to repeated requests for comments on the growing claim denials. As hard as the ILWU has fought to keep automation from taking union jobs, artificial intelligence may very pick their members’ pockets and short them on health benefits.