In this episode, I talk about Prior Authorization, what it is, how it works, how insurers use it, and why it is a major hurdle to medical care for rare and chronic disease. I also share my personal experience with prior authorization denials, including how I had to escalate one to the North Carolina Insurance Commissioner.

Prior Authorization: The Health Insurer Bureaucracy Blocking Your Care – Eps. 7 – The Fine, But Not Fine Podcast

In this episode, I talk about Prior Authorization, what it is, how it works, how insurers use it, and why it is a major hurdle to medical care for rare and chronic disease. I also share my personal experience with prior authorization denials, including how I had to escalate one to the North Carolina Insurance Commissioner.

Transcript – Eps. 7

You look fine, but you’re not fine, and that’s exactly what we’re here to talk about. Welcome to Fine, But Not Fine, the podcast about navigating rare disease healthcare battles and the messy reality of chronic illness. I’m Kelly Paul, and I’ve been living with Mycosis Fungoides since 2015. This is a space for real talk, real experiences, and practical advice, because surviving is one thing, but figuring out how to actually live, that’s the hard part.

Understanding Prior Authorization

Hey everyone, and welcome back. Today we’re diving into Prior Authorization, what it is, how it works, how insurers use it, and why it is a major hurdle to care. I’ll also share with you my own experience with Prior Authorization denials, including how I had to escalate one to the North Carolina state insurance commissioner.

Prior Authorization’s Impact on Patient Care

Now this is an episode about facts, processes and the real impact of these policies, not about hate or anger, but about awareness and action. If you don’t know what Prior Authorization is, yet count yourself lucky. At its core, Prior Authorization, you’ll sometimes hear people call it PA, is when an insurer requires pre approval before covering a prescribed treatment, test or a medication, and it’s framed as a cost control measure. But in reality, at least from this side, it often functions as a barrier to care.

Who Makes the Decisions with Prior Authorization?

Insurers say it prevents unnecessary or overly expensive treatments. But in practice, and certainly in my experience, it delays and denies necessary care and care required by the law. So, denials do not come from your doctor. They come from insurance employees, often non physicians.

My Personal Experience with Prior Authorization Denials

Now, I think my very first denial was for an oral medication, a very expensive one, one that’s in the thousands of dollars every month, and it was actually overturned relatively quickly, at least if you’re willing to accept some interference in the doctor patient relationship. But my most recent denial went through multiple levels of denial, and it was reviewed and denied by an LPN and a clinical pharmacist, neither of whom have the same qualifications as my prescribing specialist.

Understanding the Roles of LPNs and Clinical Pharmacists

For those of you who don’t know, an LPN is a Licensed Practical Nurse. This is a healthcare professional who provides basic nursing care under the supervision of a registered nurse or a physician. And LPNs typically complete a one year nursing program and must pass an exam to become licensed. And these vary from state to state.

Their responsibilities often include monitoring vital signs like blood pressure or temperature, administering medications, assisting with daily activities like bathing and dressing when you think of elder care or care for those that need assistance, and collecting samples for testing and providing wound care. They provide a valuable medical medical service, right?

And a Clinical Pharmacist is a pharmacist who works directly with healthcare teams in settings like hospitals or clinics. They primarily dispense medications and provide general patient counseling. And a Clinical Pharmacist plays an active role in patient care and treatment decisions. In general, they have six to eight years of education and training, depending on their specialization and career path, but they may not have specialized knowledge about certain diseases, especially rare conditions, and this can lead to inappropriate denials when they override or make decisions. Because that is what these insurance companies are doing, made by our specialist physicians who directly treat patients.

Prior Authorization External Review – Resulted in Overturning the Decision

So, back to my most recent denial. Only when I filed an external review request with the North Carolina Insurance Commissioner, did my insurer bring in reviewers who were qualified in dermatology. The result, they overturned their own decision.

Prior Authorization “Cost Controls” Waste Our Time and Treatment Progressions

This shows, I mean, really, it’s a perfect demonstration that prior authorization denials are often baseless, but they require us, you and me and our doctors and their medical teams, to fight to prove it. And they waste valuable time we could have been using to treat our conditions, and for me, that’s Mycosis Fungoides, a rare and incurable cancer.

Why Insurance Companies May Overturn Prior Authorization Denials

So why would they overturn something they denied multiple times. Now, once an external review is requested, insurers are required to submit their records for third party evaluation, and this can expose flawed or insufficient reasoning, or as I sometimes wonder, strategic reasoning they don’t want others to know.

They may deny, hoping a patient gives up, but once someone escalates it, they realize they may lose and be held accountable. And I want to share some stats here with you now.

The he Harvard TH Chan School of Public Health, along with some others, another foundation and NPR, I believe, conducted an income inequality report, and part of that report was focused on prescription drugs and people’s ability to pay for them, and among those who had prescription coverage but their insurer denied paying it? Those with the lowest incomes, 51% did not fill the prescription. 51% y’all, that’s abysmal, and those with the highest income, we filled them, right? I mean, there’s just something wrong with that.

Now, external reviews often involve specialists who actually understand the medical necessity, unlike internal reviewers who may not have relevant expertise, right? I said Licensed Practical Nurse and a Clinical Pharmacist led my denials. When they did their review, they brought in qualified Dermatologists who overturned it.

They also have legal and reputational risk if they’re found to be denying necessary care arbitrarily, they could face regulatory scrutiny and even lawsuits. And the sheer volume of appeals, sometimes they overturn denial simply because it’s easier than continuing to justify them. Now I haven’t experienced that, but it’s certainly a reality, and I want to repeat that, sometimes they overturn denials simply because it’s easier than continuing to justify them. Y’all, these are fighting words.

And it’s not just the patients dealing with this. It’s doctors and their staff the hours required for appeals, for documentation, resubmissions and arguing for medically necessary care are staggering. I can estimate on my most recent denial, my doctor and her staff spent at least 10 hours dealing with it, and that’s uncompensated care they’re providing.

The Negative Costs of Prior Authorization

And a recent AMA study found that 94% of doctors say prior authorization delays necessary care, and 30% report that these delays have led to serious adverse events for patients. Additionally, an American Hospital Association report on patient denial tactics is quite eye opening. They report that hospitals spent an estimated $19.7 billion, that’s with a B billion trying to overturn denied claims, and that in 2022, 62% of prior authorization denials and 50% of initial claims denials that were appealed were overturned.

Prior Authorization Kept Me From Treatment for Three Months

My most recent prior authorization denial delayed my treatment by three months. That’s three months of my disease progressing unnecessarily, three months of pain, three months of frustration, and more than three months wondering, how has it harmed me.

Insurers Deny Things They Legally Can Not Deny

Now the legal reality: insurers deny things they legally can not deny, but they rely on patients not knowing their rights and not having the energy to take up the fight.

The “Medical Necessity” Excuse

In my case, they kept saying it wasn’t, quote, medically necessary, and this is because the drug my doctor prescribed, according to my insurance company, was only authorized for Hepatitis C, and I don’t have Hepatitis C. Nowhere did they check, or maybe they did, the National Comprehensive Cancer Network, which outlines using that drug to treat Mycosis Fungoides.

The Poorest Bear the Greatest Impact of Prior Authorization Denials

I mentioned earlier those 51% of low income individuals who were received denials don’t pursue an appeal or external review. That’s half of all denied patients who either assume they’re out of options or can’t fight and I do not want this to continue. This is horrifying, and the reality is that many denials get overturned at the first appeal, even more get overturned when they reach external review, and that means insurers are denying care that should have been covered in the first place.

California Attempts to Address Prior Authorization

Now, in California, there is new legislation that’s been proposed that would require health insurers to explain claim denials, and while this is a step in the right direction, it I cannot see how it will stop the denial process from happening in the first place. I mean, heck, my insurer gave a reason, not medically necessary, and they were wrong.

There Should be Penalties for Unjustified Prior Authorization Denials

Now, we need broader reform, more transparency. How about penalties for insurers who wrongfully deny care? Imagine you deny a care for drug because it’s $14,000 a month. If it’s medically necessary, we’re going to charge you twice, right? Let’s put a financial penalty in there.

And we need a system where doctors, not insurance companies, make medical decisions, because make no beans about it. My insurer interfered in my medical care.

Fight Your Prior Authorization Denial

Now, if you or someone you love has faced a Prior Authorization denial, or are facing one, I’m telling you, fight it, appeal win it. Find out what the process is, because every insurance company has a required process you must go through. Go through that process. And if an external review is an option for you, go for it.

Note: some places the rules are different. Self-insured plans may not be eligible for external review, but don’t let them win by making you give up. I know it takes time I’ve been there, but by God, these people need to meet their contractual obligations. Lord knows, it’s not because they aren’t making enough profit.

Say it Louder: This Isn’t Just My Story. It’s a Pattern.

Share your story, whether it’s with friends on social media, better yet, with your lawmakers. Your experiences matter, and that’s exactly what I did. I shared my denial on social, and it really was a big driver for me starting this podcast.

We need to help each other out here, call your representatives, write them personal letters, let them know this system is broken. It needs reform and how it’s impacted you, and most importantly, do not let insurance companies decide what care you receive without a fight. The more we push back, the harder and more expensive it becomes for them to deny care unfairly.

Thanks for listening to Fine, But Not Fine. If this episode resonated with you, subscribe so you don’t miss what’s next. And if you got a story question or just need to vent, reach out. I’d love to hear from you. Until next time, take care and keep on going.