Patients and Physicians Speak Out

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.

I am deaf and prior authorization is an additional barrier to me receiving prescriptions for my health and mental wellness. Calling back doctors’ offices and playing phone tag is downright difficult for me, and my average time depending on the office is several days to two weeks in correcting the matter. I also switched insurance, and many of my medications I was already taking and doing well on required prior authorization when I went to refill. I had issues with missing doses. This feels like insurance companies practicing medicine without a license.

Medicare Advantage […] delayed responding to my PCP’s request for a prior authorization for a referral to a dermatologist to assess a small pigmented mass on my ear. The delay of 5 months was due to my [insurer] subcontracting the approval process to [another company]. It was two more months before I had a malignant melanoma removed, and it had grown more than 3 times the original size. I am now receiving immunotherapy. This may not have been necessary if it had been addressed when it was first detected.

I’m a Type 1 diabetic who EVERY year has to wait for prior authorization for the same insulin pump and continuous glucose monitor (CGM) supplies I’ve been using for YEARS with the SAME insurance company and plan. This results in me going without, begging friends, asking the doctor for extras, etc. I’m switching to a new CGM and can’t get it preauthorized without the previous [prior] authorization being removed, which I’m told can take days. More delays, less good blood sugar control. I spend so much time on the phone — including HOURS on hold— because of [prior authorization] insurance baloney and get VERY stressed out, which drives up blood sugars. I’m used to advocating relentlessly for myself unfortunately, but I fear for the people who don’t know how to, or don’t have time, or believe what they are told even when it’s the insurance company that made the mistake.

My insurance quit covering my rescue inhaler and didn’t list any on the approved list, so I had to call them. [I] was given the names of two replacements, one of which isn’t working well for me, but the other requires [prior authorization]. So, until approved, I must use an ineffective medication to breathe!

Recently I needed a lifesaving blood transfusion. This required an ER visit. Because I didn't get "prior authorization," I am now stuck paying the cost of the ER. I am 100% disabled, live on less than $1,200 a month, and have had most of the bills go over to collections because I simply cannot pay them in a timely fashion. I would like to know how someone is supposed to get "prior authorization" for a lifesaving ER visit.