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.

I am a Geriatric Social Worker in a senior residence. Prior authorization delays treatment, prolongs pain and cuts vital treatment short or off. These delays cost us all when Medicare and Medicaid patients use the ER post hospital or rehab discharge or while awaiting insurance approval for a procedure.

I work at a urology practice. When I started here the only procedures requiring prior authorizations were surgeries. Now medications, radiology, and in-office procedures require prior authorization or you do not get paid. Often new prior authorization requirements are buried deep within some emailed network bulletin. Insurers are famous for changing prior authorization requirements. They just started requiring us to request prior authorizations on all chemo medications injected or infused through a portal. The questions are often confusing and time consuming even to the physicians. We have had patients that have had to put off certain treatments because it takes so long to get a prior authorization back or the hoops we have to jump through are increasingly tedious.

PA affects me absolutely f***inglutely. I'm an internist in a rural north GA town. It absolutely INFURIATES ME when I have to call someone who doesn't know the difference between a jaw and sinuses yet has the power to deny a patient a study or treatment. They are so completely unaware of anything medical and I had to go through at least 10 years of training before I could touch a patient.