The Dark Reality of Pre-Authorization

In his October 28, 2109 Opinion piece published by The Philadelphia Inquirer, Ross Waetzman opened with this harrowing sentence, “I almost died because of insurance prior authorization rules.” His story went on to share the details of how he nearly died as a result of the decision made by his insurer, Independence Blue Cross (“IBC” or “IBX”), to deny authorization of benefits for a test that had been recommended by Mr. Waetzman’s cardiologist.

The test Mr. Waetzman’s cardiologist had recommended was a cardiac catheterization. The test was necessary because Mr. Waetzman’s history of chest pain had been increasing in intensity, despite lifestyle changes he had made in an attempt to curb his symptoms. The cardiac catheterization was recommended by Mr. Waetzman’s cardiologist after less-invasive tests had been performed. Those less invasive tests, an EKG and a coronary calcium test, revealed that Mr. Waetzman was in the top 10% for his age and race for calcium deposits on his coronary arteries. With such deposits known to result in reduced blood flow to the heart, the cardiac catheterization was recommended to determine if Mr. Waetzman’s chest pain was a result of a blocked artery.

Unfortunately, when Mr. Waetzman’s cardiologist, Dr. Kenneth Mendel, called IBX, he was informed that “prior-authorization” for the cardiac catheterization was denied. IBX claimed that Mr. Waetzman did not meet all the necessary criteria to have the test and his only available option was to appeal the denial.

Three days later, Mr. Waetzman endured two attacks that were so severe his wife took him to an emergency room. There he underwent an emergency cardiac catheterization that revealed a 95% blockage in one of his arteries known as the “widow maker,” and an 80% blockage in another artery. Emergency surgery was performed. Three stents were inserted, and Mr. Waetzman is alive and doing well today.

Prior authorization can also be referred to as: “preauthorization,” “pre-auth” “precertification,” “prior approval,” “prior notification,” “prospective review” and “prior review.” Many terms that all mean the same thing: an insurance company requires your health care provider to obtain approval in advance of providing you with treatment such as a procedure, service, device, supply, or medication. As many reading this know all too well, without insurance granting their blessing of pre-auth, benefits and coverage will be denied.

The history of pre-auth can be traced back to what likely comes as no surprise to anyone reading this: insurance’s attempts to keep care costs under control. Unfortunately, pre-authorization has resulted in significant burdens placed on physicians and their practices, costing them, on average, 20 hours per week, with one study equating that to roughly $83,000 per year, per physician. Additionally, in one poll, 94% of physicians thought pre-auths were “never or almost never” appropriate.

More importantly than its failure to control costs of treatment, the industry-developed precertification, pre-auth, or whatever name you call it, it has failed providers and patients alike. Sometimes this failure results in near-death experiences, as it did for Mr. Waetzman. Other times, this failure results in death, as it did for Anna Westin who died as a result of anorexia, after insurance denied treatment.

Sadly, in one poll of eating disorder specialists, 1 in 5 providers believe that insurance companies are indirectly responsible for the death of at least one of their patients and early all (98.1%) believe federal legislation will be necessary to alleviate this situation.

While it should not take an appeal or lawsuit, or legislation, before insurers do the right thing, stories like Anna’s and Mr. Waetzman’s remind us that is often what it takes. If you have been denied treatment, a procedure or medication, whether for your mental or physical health, or both, please contact us today for an no-cost evaluation of your case. We care and we can help.

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