For anyone who hasn’t had to deal with lots of medications and appointments and prior authorizations, please take a moment to be super grateful for this. For those of us who have an ongoing illness (chronic or terminal), I suspect that you might be shuddering or feeling the hairs raise on the back of your neck or perhaps feel a little nauseous. Or maybe that’s just me.
Here’s how prior authorizations work from a doctor/comedian’s perspective … (and really, you should just follow Dr. Glaucomflecken on social media and listen to his amazing podcast — it’s amazing how humor can be really educating):
As you’ve heard if you listened to the TikTok video, a prior authorization requirement is a hurdle that medical professionals have to deal with when ordering certain tests, surgeries, medications, etc. Basically, the ordering professional has to prove to the relevant insurance company that what they are prescribing for their patient is the right move. I’m sure there are good reasons for many things that insurance companies do; there are certainly bad actors in the medical profession as with so many others. At the same time, in my experience, this requirement causes a whole lot of unnecessary delays.
Recently, I’d experienced an issue with a prior authorization (really a continuation) of the oral chemotherapy I’ve been taking for nearly eighteen (18) months. There were a variety of issues and break downs in communication that resulted in me missing nearly two whole cycles of the medication. Each issue, each hurdle, each problem were entirely beyond my control as a patient. I tweeted a bit about my frustrations and ended up contributing to an article, which you can read here: https://ascopubs.org/doi/10.1200/EDBK_100036. ASCO is the American Society of Clinical Oncologists and they are taking some steps to help streamline the system for the benefit of everyone involved.
I get that the topic of prior authorizations is complicated and there are lots of different perspectives. Here’s mine, as a patient:
- Patients have no control and usually no involvement with the interactions between our medical providers and our insurance companies.
- Typically, the only interaction we have with this process is when it breaks down and we’re out of the medication that keeps us alive.
- While I get that missing a dose or two or more may not mean a whole lot in the trajectory of a cancer experience, the negative affects on our mental health can be catastrophic.
- The gamesmanship I’ve seen between medical providers and insurance companies is shameful, in my opinion.
As a lawyer, I’m very aware of the requirements of the contract with my insurance company. Not many patients are aware of the time requirements for insurance companies to respond to information received from a medical provider. My oncologist’s office, for instance, was faxing requests to the wrong fax number for about a week without a meaningful response. The fax from my insurance company (ostensibly satisfying the response requirement in the contract) simply asked for more information, via fax of course, and never pointed out that the number was incorrect for my type of policy.
Checks and balance are important and I’m all for accountability; at the same time, centering efforts around what is best for the patients, versus what is best for the system and profitability, would be a big step in the right direction. Too many of us experience extreme frustration with all the extra steps and extra hurdles for us and our medical teams. To me, if the system is causing this much angst and frustration and, yes, abuse of patients, something has to change.
I’m hopeful we may see some changes.
No Half Measures 
I couldn’t agree more! I just went through this earlier this year when I changed treatments. First of all I was really scared because I had changed treatments twice in 6 months. Then I found out my insurance company denied my initial keytruda claims saying it was experimental for my type of cancer, ER/PR+. The infusions cost well over $32K a piece. I was really scared I would have to stop taking a drug that was finally working for me!! Thankfully the situation worked out in the end but the mental stress involved to get to that point was unbearable. I really like what you said about all of this being abusive to patients because that is really true. A lot of people don’t talk about the mental stress involved with not knowing if your insurance company will cover treatment you need and it the treatment you need will financially ruin your family. This is the hardest part of being a cancer patient for me. Thank you for all you do to bring awareness to our experiences!
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I’m so sorry you have experienced this as well. I totally agree, the mental stress can often be worse than many of the other side effects. Appreciate you reading and commenting!!
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Reblogged this on By the Mighty Mumford and commented:
HEALTH INSURANCE—-MISSED THE VIDEO! 😦
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Thank you for sharing!!
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Oh goodness as soon as I saw the title of this, I just started laughing. Talk about singing to the choir. It’s an absolutely horrible process, and that comedy routine really has some truth to it! I’ve never understood how the insurance requires your primary doctor to send you to a specialist (depending on whether you have an HMO), because they have expertise, but when the specialist orders something, the “insurance guy” then questions the doctor about his/her specialty or expertise. I am embarrassed by my insurance when they do this to my doctors. It’s so hard to find good doctors to begin with, and the last thing you want to do is become a problem to a good doctor because of your insurance. So backward.
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I totally agree, so backwards!! I tell all my doctors now (especially that I have a new team) to make sure to keep me in the loop when these things happen. I’ve fussed at my insurance company so much that I now have go-to people rather than messing with the front line people. It’s horrible that we have to get involved so often to make sure that things work the way they are supposed to.
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Just went through something similar with our local hospital!! I’ve been waiting for an MRI order to be sent and approved via insurance and my oncologist’s office. I went almost a week without the hospital calling me to schedule — I left numerous messages and so did my insurance and onc office! I knew they had all the information to call me. So I had to take it into my own hands and I went personally to the hospital and just as “sweet as pie” told them I either needed this to be scheduled while I wait or I needed an administrator. Oddly enough (not) they scheduled it right then and there! I mean, come on!! A little different than what you are talking about but same idea! This is NOT what we should have to stress about!
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So true!! Amazing how often it takes quiet persistence (or loud persistence) to get basic things accomplished. Wishing it was easier for you and for all of us. Also, kudos for advocating for yourself!!
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