Patients and Physicians Speak Out

Being a type 1 diabetic, I need insulin pumps and glucose testing supplies. I have been using Omnipod Classics for almost 10 years. The company that I now work for had a health insurance option, HealthNet of Oregon. They immediately rejected my Omnipods because they weren't a necessity. I started paying out of pocket for Omnipod Classics and Dexcom G5 continuous glucose monitoring (CGM) system. I eventually dropped the Dexcom and started testing manually, because I could not afford $3,000 for a 90-day supply. 

I ended up spending over $10,000 on credit cards trying to keep my Omnipod supply. In late 2022, I found out my Omnipod Classics were being phased out, so I needed to upgrade. I tried for a whole year to get them approved. My doctor’s office goes through every hoop to send preauthorization paperwork only to have it denied with the reason being ‘not enough info.’ 

My doctor’s office sent copies of emails with lengthy explanations and records proving the necessity. It wasn't until Healthnet appointed me a case worker that I got a year-long override to have Omnipod 5 and Dexcom G6 CGM system. Now, in 2024, I am still fighting to be reimbursed for the out-of-pocket expenses for medications that should've been approved from the start.

I was denied a simple lidocaine cream because I could buy it over the counter. Now, I couldn’t buy the same strength over the counter, and nothing worked but this prescribed cream. What was once covered easily became a prior authorization medication. [It’s] super frustrating for such a simple prescription – I can’t even imagine having to wait for something like a cancer medication or insulin because of a prior authorization issue. Obviously, if your doctor is prescribing it, then they feel it is the best medication for you. The insurance company shouldn’t dictate what’s best for patients — they aren’t MDs.

I am a maternal-fetal medicine specialist in Nevada. More than 99% of the time, we have to obtain prior authorization for a procedure (usually an ultrasound on a pregnant patient). However, it takes more than a week to get the authorization back from the insurance company. Then, we have to contact the patient and get her scheduled. Now, she has had to wait weeks for an ultrasound only to find out there was a lethal birth defect. WHY should we have to obtain a prior authorization when it is always approved after a delay? How can this be good care? 

It definitely costs our practice a great deal of money to hire people to obtain prior authorization, not to mention the poor patient who has to wait for the insurance company to approve something that we knew would be approved. It is just bad medicine, and the patient suffers the most.

Recently, [I] had back surgery and was discharged on medications for pain recommended by the neurosurgeon. They had to be prior authorized, and one was delayed so long that I did not even get it many days later when it was finally approved… I just had to grin and bear the pain. I am a primary care physician, and we are not exempt from the red tape created to enrich insurance companies that goes under the name of "prior authorization."

Nothing I love more than my morning cup of coffee to go alongside my daily peer-to-peers before clinic is even open yet. Extra exciting when the “peer” opens the conversation with “I am a RETIRED PSYCH (or other unrelated field) DOC with BCBS calling to discuss why your (insert GASTROENTEROLOGY specific procedure/testing/medication) was denied.” 

And then they literally ask me questions that they could have answered themselves by reading the notes I provided them 2 months ago, and again with the letter of medical necessity I wrote them, and again with the appeal I had to do. It takes me 8 weeks of work for what could have been squashed day one if the system were not broken. 

It’s coming to a point where the easier thing to do is basically nothing for the patient, and we wonder why the ER is packed. People see 16 specialists, people seek second, third or fourth opinions, further delaying care. I hate this.

It’s a burnout to nursing staff to submit and follow up on medication for prior authorizations. As a nurse, my time should not be used for phone calls to insurance for follow-ups or appeals.