Patients and Physicians Speak Out

While waiting for approval for a heart surgery, my friend died of a heart attack!

Prior authorization places an extra step between physicians and patients, one which benefits the insurance companies, places the insurance company in a position of determining appropriate medical treatment on the basis of cost to the company, and is confusing and cumbersome for the patient, not to mention delaying the treatment. It is absolutely a matter of profit trumping people.

I am a senior citizen and a military veteran. My wife recently had an increase in one of her medications ordered by her doctor. [The insurance company] refused to fill the prescription as written, leaving her at 2/3 of the required dosage. The doctor filed the form for a prior authorization and [the insurance company] refused to honor it. As I was preparing a detailed appeal letter, we received a second letter from [the insurance company] saying that they approved the increased dosage. Had they not made the approval, my next step would have been to have the doctor write a prescription for the most expensive alternative medicine available (some of them approach $1,000 for a 3-month supply). Here's where the prior authorization went wrong in this case. The reason for approval was a clause in the contract between [the insurance company] and [the pharmacy benefit manager] that says [the pharmacy benefit manager] must fill prescriptions using the cheapest available method. Prior authorization is not always about medical need - it's all about the money.

I recently encountered a denial of treatment. I have been fighting ovarian and breast cancer stage 3c since 2013. My [cancer antigen 125] has proven to be accurate and indicative of active disease. I have been on a maintenance regimen, but my marker started creeping [up]. Also picked up a [pulmonary embolism] 3 months ago which is resolved with anticoagulation. This is the fourth or fifth recurrence. I’ve lost track. [Prior authorization] for chemotherapy treatment was sent to [the] insurance company. Denied. The denial letter sent to me reported the determination was made by a board-certified rheumatologist, not an oncologist. My oncologist, upon hearing of the denial, requested an immediate phone appeal with the physician. The insurance company wanted to know why we didn’t wait until we actually saw a tumor. I guess they would rather have my cancer advance more. Not to mention the possibility of an emergency bowel obstruction from a tumor while on meds that would cause bleeding. No common sense. My first thought of the denial was that my insurance company had decided it was time for me to die. My second thought was it was an automatic denial to save money.

I have always thought prior authorization was the biggest waste of time for all involved in the process. If a physician deems the procedure, test, medication, etc. medically necessary, why does it have to be scrutinized by someone who probably doesn't even work in the same area of expertise or [have the] same level of education to make that decision?

The insurance companies really try to justify prior authorization as a safety measure? We all know it is to maximize their profit. They say lack of it will increase premiums? How about lower their outrageous profits? Such evil entities.