Prior Authorization is a Barrier to Care

My mom recently experienced respiratory and heart failure, and she had to get a tracheostomy so that she can rely on a ventilator to breathe. After staying in ICU for two weeks, my mom’s care team determined that she was stable enough to be transferred to a long-term acute care (LTAC) facility so that she could be weaned off the ventilator. 

This is when our worst nightmare happened. Her Medicare Advantage plan from Aetna denied the prior authorization request for LTAC admission. They took five days to reach their decision, and they did not provide any sufficient explanation on why they denied the request. My mom’s ICU team was befuddled and wanted to speak with the clinical review team for a peer-to-peer conversation. Aetna said it was “too late” for a peer-to-peer conversation, and that the only recourse we had was to appeal. We appealed their decision, and it took them another five days to review our appeal, which they upheld. 

The whole process is convoluted and truly Kafkaesque. Aetna’s decision-making process is arbitrary and truly inhumane. What’s even more shocking is that my mom’s ICU team told me that they see this happen all the time, and that many patients in my mom’s situation just give up and pursue hospice care. 

Fortunately, we had the option to disenroll my mom from her Medicare Advantage plan and have her go back to traditional Medicare, which does not require prior authorizations for medically necessary services.