Insurance Companies and the Prior Authorization Maze

Imagine you wake up with blurry vision. Your doctor refers you to a specialist but your insurance blocks the referral. Call me to defend why you think this patient needs this. That causes you to go blind. Imagine you have multiple sclerosis. Without warning, your insurance stops your medications. No, you cannot give this drug. So you become paralyzed. Imagine your father has cancer. His doctor orders an M.R.I. No, you cannot order this imaging. Prescribes chemotherapy. Have you considered this other less expensive option? His insurance causes delay after delay. No, you don’t need this surgery. He dies. An absurd process has infiltrated American health care. It’s called prior authorization. Here’s how it works. Before your doctor provides a treatment, your insurance requires them to prove it’s necessary. This is often a time-consuming process that can cause dangerous delays. I’m sorry. Your cancer could be cured, but we need to wait for the insurance company to approve your chemotherapy. That’s Dr. Jain. She’s barricaded by prior authorizations daily. This is a really big issue and it impacts every single person in this country who has insurance. Prior authorization was actually created to save you money. Decades ago, it was used sparingly, only to make sure expensive treatments like long hospital stays were absolutely necessary. But now — It’s devolved into now a system where a lot of times, things are really denied for no reason. Even everyday medications now require insurance approval. It could be for medications to treat heartburn. ADHD medication. Test strips for patients to be able to check their blood sugar. Chemotherapy. Prozac. When I prescribe a medication, I would say 95 percent of the time, I have to obtain a prior authorization. New York Times Opinion interviewed more than 50 doctors and patients. Their experiences suggest that insurance companies often weaponize this mundane process in order to control doctors and inflate their profits. If they deny care or they delay care, that’s money the insurance company gets to keep. The way that they profit is to deny care. As prior authorization has spread, delays in care have become normalized. So have tragedies. One in three doctors say that it’s caused a serious medical issue or even the death of one of their patients. Ocean went blind. It was like the insurance company telling me that my life didn’t matter. Michael couldn’t walk or stand for four months. It’s like, I am scared of M.S. But my fear as of right now is more of the insurance company. And Vivian lost her father. I spent so much time on the phone, writing letters, faxing, that I didn’t get to spend that time with my father. This is medical injustice disguised as paperwork. When your prior authorization is denied, you have three options. You could just pay out of pocket. But health care is so ridiculously expensive that that’s not realistic. You can give up. That’s what happens up to 80 percent of the time — a win for your insurance company. Or your doctor can go to bat for you. When our prior authorizations get denied, we have to do what’s called a peer-to-peer. A peer-to-peer is supposed to be a phone call where you call somebody who is your peer to justify the treatment that you want to deliver. I’m a pediatrician and sometimes I’ll end up talking to a neurologist. People who couldn’t pronounce the names of the drugs I was trying to prescribe. Oftentimes it’s not even a physician. Now imagine you have to do that 5 to 10 times a day. What’s even more ridiculous about this whole process is that after we go through all of this, if you’re really a determined provider, you’ll probably get your drug or your procedure authorized. Insurance companies say that this process helps “reduce the cost of expensive treatments,” “ensure safety,” and “lower the total cost of care.” But what it’s actually doing is creating a lot of expensive bureaucracy. We have four full-time employees who their sole focus is on obtaining prior authorization for medications to treat Crohn’s disease and ulcerative colitis. And that’s just for one disease state. By one estimate, the U.S. spends about $35 billion a year on the administrative costs of prior authorization. These resources could be devoted to patient care, answering phones in a timely fashion. I might actually get to go home and see my family on a regular basis. In an admission of sorts, some companies have actually pledged to reduce prior authorizations. But those efforts only scratch the surface. I am a board-certified gastroenterologist. I know what I’m doing, only to be blockaded by all of this bureaucracy, red tape, which really only serves to enrich the insurance companies. Cigna made $5.2 billion in profit last year. Elevance made 6 billion. United Healthcare made $22 billion. I had a patient who had a new diagnosis of lymphoma. And the insurance company was giving us a hard time to give the chemotherapy. I got someone on the phone. And I told the person, I said, “I need your name. Because when this young man dies, I want to tell his parents who was the reason behind it.” I went home and I cried after I hung up the phone because I was so emotionally exhausted. And that was just one patient. I had seen 25 other patients that day. And many of them would eventually need prior authorizations as well. Prior authorization gives your insurance company more power than your doctor. Now, there are some complicated cases when it makes sense to double check that your doctor isn’t unnecessarily overprescribing. Imagine you’ve had a cancerous tumor removed. To be extra safe, your doctor recommends an additional treatment, but it costs $170,000. On the one hand, I can see where insurance companies are coming from with wanting to take a careful look at these expensive treatments. Then on the other hand, I’m a human and I’m a young mom. What’s my life worth? Sara’s insurance denied the treatment. The question is, do you think they made that decision based on what was in her best interest or theirs? In many countries, these tough ethical decisions about what is covered are made by governments, not for-profit insurance companies. The government should abolish prior authorization or at the very least reform it. My goal with Senate Bill 247 is to reform the prior athorization process. House Bill 3459 creates a streamlined prior authorization process known as, quote, ‘gold carding.’ A handful of states have created gold card programs. Doctors who have successfully obtained prior authorizations in the past are exempt from needing to obtain them again. All states and the federal government should pass laws like these. Your insurance should not be a barrier between you and the health care you need. I finally got the authorization to see the neuro-ophthalmologist after 12 weeks. And he said, “We’re going to do this surgery but it’s only to preserve the vision you have left. If we had seen earlier, that would have been a different story.” Maybe I’d be able to see now. Maybe I’d have a different life.