Prior Authorization: The Health Insurer Bureaucracy Blocking Your Care - Eps. 7

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.

Episode Transcript

Kelly Paul (00:01):
You look fine, but you're not fine, and that's
exactly what we're here to talkabout. Welcome to Fine, But Not
Fine, the podcast aboutnavigating rare disease
healthcare battles and the messyreality of chronic illness. I'm
Kelly Paul, and I've been livingwith Mycosis Fungoides since
2015. This is a space for realtalk, real experiences and

(00:26):
practical advice, becausesurviving is one thing, but
figuring out how to actuallylive, that's the hard part.
Hey everyone, and welcome back.Today we're diving into Prior
Authorization, what it is, howit works, how insurers use it,

(00:49):
and why it is a major hurdle tocare. I'll also share with you
my own experience with PriorAuthorization denials, including
how I had to escalate one to theNorth Carolina state insurance
commissioner.
Now this is an episode aboutfacts, processes and the real

(01:09):
impact of these policies, notabout hate or anger, but about
awareness and action. If youdon't know what Prior
Authorization is, yet countyourself lucky. At its core,
Prior Authorization, you'llsometimes hear people call it
PA, is when an insurer requirespre approval before covering a

(01:35):
prescribed treatment, test or amedication, and it's framed as a
cost control measure. But inreality, at least from this
side, it often functions as abarrier to care.
Insurers say it preventsunnecessary or overly expensive

(01:55):
treatments. But in practice, andcertainly in my experience, it
delays and denies necessary careand care required by the law.
So, denials do not come fromyour doctor. They come from
insurance employees, often nonphysicians.

(02:18):
Now, I think my very firstdenial was for an oral
medication, a very expensiveone, one that's in the thousands
of dollars every month, and itwas actually overturned
relatively quickly, at least ifyou're willing to accept some
interference in the doctorpatient relationship. But my
most recent denial went throughmultiple levels of denial, and

(02:42):
it was reviewed and denied by anLPN and a clinical pharmacist,
neither of whom have the samequalifications as my prescribing
specialist.
For those of you who don't know,an LPN is a Licensed Practical
Nurse. This is a healthcareprofessional who provides basic

(03:04):
nursing care under thesupervision of a registered
nurse or a physician. And LPNstypically complete a one year
nursing program and must pass anexam to become licensed. And
these vary from state to state.
Their responsibilities ofteninclude monitoring vital signs
like blood pressure ortemperature, administering

(03:26):
medications, assisting withdaily activities like bathing
and dressing when you think ofelder care or care for those
that need assistance, andcollecting samples for testing
and providing wound care. Theyprovide a valuable medical
medical service, right?
And a Clinical Pharmacist is apharmacist who works directly

(03:47):
with healthcare teams insettings like hospitals or
clinics. They primarily dispensemedications and provide general
patient counseling. And aClinical Pharmacist plays an
active role in patient care andtreatment decisions. In general,
they have six to eight years ofeducation and training,
depending on theirspecialization and career path,

(04:10):
but they may not havespecialized knowledge about
certain diseases, especiallyrare conditions, and this can
lead to inappropriate denialswhen they override or make
decisions. Because that is whatthese insurance companies are
doing, made by our specialistphysicians who directly treat

(04:32):
patients.
So, back to my most recentdenial. Only when I filed an
external review request with theNorth Carolina Insurance
Commissioner, did my insurerbring in reviewers who were
qualified in dermatology. Theresult, they overturned their
own decision.
This shows, I mean, really, it'sa perfect demonstration that

(04:55):
prior authorization denials areoften baseless, but they require
us, you and me and our doctorsand their medical teams, to
fight to prove it. And theywaste valuable time we could
have been using to treat ourconditions, and for me, that's
Mycosis Fungoides, a rare andincurable cancer.

(05:17):
So why would they overturnsomething they denied multiple
times. Now, once an externalreview is requested, insurers
are required to submit theirrecords for third party
evaluation, and this can exposeflawed or insufficient
reasoning, or as I sometimeswonder, strategic reasoning they

(05:37):
don't want others to know.
They may deny, hoping a patientgives up, but once someone
escalates it, they realize theymay lose and be held
accountable. And I want to sharesome stats here with you now.
The he Harvard TH Chan School ofPublic Health, along with some
others, another foundation andNPR, I believe, conducted an

(06:01):
income inequality report, andpart of that report was focused
on prescription drugs andpeople's ability to pay for
them, and among those who hadprescription coverage but their
insurer denied paying it? Thosewith the lowest incomes, 51% did
not fill the prescription. 51%y'all, that's abysmal, and those

(06:27):
with the highest income, wefilled them, right? I mean,
there's just something wrongwith that.
Now, external reviews ofteninvolve specialists who actually
understand the medicalnecessity, unlike internal
reviewers who may not haverelevant expertise, right? I
said Licensed Practical Nurseand a Clinical Pharmacist led my

(06:50):
denials. When they did theirreview, they brought in
qualified Dermatologists whooverturned it.
They also have legal andreputational risk if they're
found to be denying necessarycare arbitrarily, they could
face regulatory scrutiny andeven lawsuits. And the sheer
volume of appeals, sometimesthey overturn denial simply

(07:12):
because it's easier thancontinuing to justify them. Now
I haven't experienced that, butit's certainly a reality, and I
want to repeat that, sometimesthey overturn denials simply
because it's easier thancontinuing to justify them.
Y'all, these are fighting words.

(07:34):
And it's not just the patientsdealing with this. It's doctors
and their staff the hoursrequired for appeals, for
documentation, resubmissions andarguing for medically necessary
care are staggering. I canestimate on my most recent
denial, my doctor and her staffspent at least 10 hours dealing

(07:58):
with it, and that'suncompensated care they're
providing.
And a recent AMA study foundthat 94% of doctors say prior
authorization delays necessarycare, and 30% report that these
delays have led to seriousadverse events for patients.
Additionally, an AmericanHospital Association report on

(08:21):
patient denial tactics is quiteeye opening. They report that
hospitals spent an estimated 19point 7 billion, that's with a B
billion trying to overturndenied claims, and that in 2022,
62% of prior authorizationdenials and 50% of initial

(08:45):
claims denials that wereappealed were overturned.
My most recent priorauthorization denial delayed my
treatment by three months.That's three months of my
disease progressingunnecessarily, three months of
pain, three months offrustration, and more than three

(09:07):
months wondering, how has itharmed me.

Now the legal reality (09:12):
insurers deny things they legally can not
deny, but they rely on patientsnot knowing their rights and not
having the energy to take up thefight.
In my case, they kept saying itwasn't, quote, medically
necessary, and this is becausethe drug my doctor prescribed,

(09:36):
according to my insurancecompany, was only authorized for
Hepatitis C, and I don't haveHepatitis C. Nowhere did they
check, or maybe they did, theNational Comprehensive Cancer
Network, which outlines usingthat drug to treat Mycosis
Fungoides.
I mentioned earlier those 51% oflow income individuals who were

(09:59):
received denials don't pursue anappeal or external review.
That's half of all deniedpatients who either assume
they're out of options or can'tfight and I do not want this to
continue. This is horrifying,and the reality is that many

(10:20):
denials get overturned at thefirst appeal, even more get
overturned when they reachexternal review, and that means
insurers are denying care thatshould have been covered in the
first place.
Now, in California, there is newlegislation that's been proposed
that would require healthinsurers to explain claim

(10:41):
denials, and while this is astep in the right direction, it
I cannot see how it will stopthe denial process from
happening in the first place. Imean, heck, my insurer gave a
reason, not medically necessary,and they were wrong.
Now, we need broader reform,more transparency. How about

(11:01):
penalties for insurers whowrongfully deny care? Imagine
you deny a care for drug becauseit's $14,000 a month. If it's
medically necessary, we're goingto charge you twice, right?
Let's put a financial penalty inthere.
And we need a system wheredoctors, not insurance
companies, make medicaldecisions, because make no beans

(11:23):
about it. My insurer interferedin my medical care.
Now, if you or someone you lovehas faced a prior authorization
denial, or are facing one, I'mtelling you, fight it, appeal
when it find out what theprocess is, because every
insurance company has a requiredprocess you must go through. Go

(11:43):
through that process. And if anexternal review is an option for
you, go for it.

Note (11:49):
some places the rules are different. Self-insured plans
may not be eligible for externalreview, but don't let them win
by making you give up. I know ittakes time I've been there, but
by God, these people need tomeet their contractual
obligations. Lord knows, it'snot because they aren't making
enough profit.
Share your story, whether it'swith friends on social media,

(12:13):
better yet, with your lawmakers.Your experiences matter, and
that's exactly what I did. Ishared my denial on social, and
it really was a big driver forme starting this podcast.
We need to help each other outhere, call your representatives,
write them personal letters, letthem know this system is broken.

(12:35):
It needs reform and how it'simpacted you, and most
importantly, do not letinsurance companies decide what
care you receive without afight. The more we push back,
the harder and more expensive itbecomes for them to deny care
unfairly.

(12:57):
Thanks for listening to Fine,But Not Fine. If this episode
resonated with you, subscribe soyou don't miss what's next. And
if you got a story question orjust need to vent, reach out.
I'd love to hear from you. Untilnext time, take care and keep on
going.