Permission to Practice: Doctors, patients say insurance prior-authorizations put profits over people

(InvestigateTV) - Reeling from a diagnosis of bone cancer in her right hip, Kathleen Valentini and her husband traveled from North Carolina back to their native New York to seek care.

The hospital had successfully treated her cervical cancer 15 years before, but this time the prognosis Kathleen received in April 2019 was far less optimistic. To treat the aggressive sarcoma, surgeons would need to amputate her right leg, hip and a portion of her pelvis, then she would undergo strong chemotherapy.

The devastating news was worsened by another observation made by the care team: If Kathleen had been seen sooner, the cancer would have most likely been treatable with chemotherapy alone.

“[Her oncologist] said, ‘Had you come here at the very beginning, then it would have been a much easier process,’” Kathleen’s husband Val said in an interview with InvestigateTV.

That beginning was months earlier on February 4, 2019, when her orthopedic doctor ordered an MRI of her hip. She didn’t receive one until nearly six weeks later.

Kathleen’s insurance plan required her physician to obtain “prior-authorization” for the scan — a process used almost unilaterally across the commercial health insurance industry where doctors submit a request and the patient’s insurance plan decides if it will provide coverage.

Approval of these requests often hinges on whether or not a plan determines the test or procedure to be “medically necessary” — with insurance companies defining necessity using their own guidelines.

The request for an MRI submitted by Kathleen’s doctor was initially denied, and the appeal for reconsideration took weeks before the insurance company relented. By then, the cancer had progressed, and Kathleen ultimately underwent the massive amputation and chemotherapy.

In November 2020, Kathleen Valentini lost her cancer battle at age 50, leaving behind her husband and a teenage son.

Physicians across the country say prior authorization policies interfere with their ability to care for their patients and lead to worse health outcomes. Doctors also say the administrative work required to process requests and appeals is an ever-growing burden on them and their staffs.

InvestigateTV analyzed the prior-authorization policies of nearly 100 commercial health insurance companies for some of the most common tests and procedures and found whether a patient needs advanced approval varies not only company to company, but sometimes state to state or even plan to plan.

What’s more, InvestigateTV found in many cases the employees responsible for the initial administrative processing of prior authorization requests are not required to have education or training in the medical field.

For their part, insurers argue requiring prior authorization protects patients and reduces waste in healthcare by cracking down on superfluous tests or procedures.

Companies also say improving technology and innovative processes are steadily reducing the burden of prior authorizations, and any determinations made are only about paying for care — that it’s still up to a patient and their doctor what care is received.

Critics, however, claim insurers are essentially practicing medicine by way of policy and should be legally held to that standard.

“At some point, somebody has to be held accountable,” Val Valentini said.

A Burden on Doctors

Requiring prior authorization — also sometimes referred to as “pre-authorization,” “pre-certification” or “prior approval” — is not a novel cost-management strategy.

Consternation over the practice is also not new.

In 2018, medical trade groups and major players in the insurance industry signed a “Consensus Statement on Improving the Prior Authorization Process,” which outlined pathways for improvement such as more selective application of the process, greater transparency, increased automation and regular reviews to adjust volume.

However, physicians polled by national medical trade groups report the volume and burden of requests required for what many consider to be standard medical care have continued to grow.

In a 2022 American Medical Association survey of physicians, responding doctors reported an average of 45 requests per-physician, per-week, up from an average of 31 per-week reported in the 2018 survey. The previous year’s survey found 84% of respondents said they’d seen an increase in the number of prior authorizations required over the preceding five years.

The Medical Group Management Association found similar results in its own 2022 poll: 79% of the association’s members surveyed reported prior authorization requests had increased over the previous 12 months.

It isn’t just the number of requests doctors say is a burden, either.

According to the AMA survey, physicians and their staffs spend an average of 14 hours, or nearly two business days, processing prior authorization requests and any associated appeals. Nearly two in five physicians said they have a staff member solely dedicated to prior authorization.

“That’s time that we, frankly, just don’t have,” said Dr. Gabe Charbonneau, a Montana family physician and co-founder of the grassroots organization Medicine Forward, which along with the American College of Physicians has made addressing prior-authorization its cornerstone issue.

What does the plan say?

Part of that time burden, according to AMA survey respondents, is due to how challenging it can be to even determine if a patient’s plan requires prior authorization for a specific test, procedure or medication.

In the organization’s 2021 survey, nearly two-thirds of respondents, 62%, said it is at least somewhat difficult to determine if a medical service requires prior authorization. One in 10 classified it as “extremely difficult.”

InvestigateTV attempted to replicate what a medical office experiences by looking at the prior-authorization policies of nearly 100 commercial health insurance companies listed as members of national health insurance trade associations, and whether they required a request for medical tests and procedures that are among the most common according to data from Centers for Disease Control and Prevention.

Lists of medical services requiring prior authorization were available for 96 of those companies, which reporters accessed directly from each insurer’s website and were the most-recent versions the team could find as of May 2022 and again as of January and February 2023.

InvestigateTV then looked at each plan document to determine if each procedure or test did or did not require prior authorization, or if the prior authorization requirement was dependent on certain factors.

According to the documents, requirements for prior authorization for the same kind of medical service can differ by company.

Patients with Elevance (Anthem), EmblemHealth or Aetna plans, for example, generally do not need prior authorization for a basic cardiac stress test, but those with certain United Healthcare plans do.

Most of the major plans require prior authorization for elective spinal fusion, but for patients with Highmark plans, it depends on the specific bones being fused.

Geography can also affect the requirements — even within the same parent company.

For example: InvestigateTV found differences between plans offered through Blue Cross Blue Shield, which has 34 “independent and locally operated” BCBS companies across the country. According to the published lists, prior authorization for outpatient balloon sinus dilation procedures is required for BCBS Oklahoma customers, but not for BCBS Massachusetts.

InvestigateTV also contacted a healthcare information educator in Louisiana, Jacqueline Jones, who replicated a portion of the team’s research.

Jones looked at sub-set of tests and procedures and the plans of some of the nation’s largest insurance companies.

She too found variations between companies for the same type of procedure or test, and sometimes requirements come down to an individual plan.

“In many cases, it depends on the specific health plan the patient may have,” Jones said after her review. “Many health plans today have several different options for the consumer to choose from.”

She noted in some cases, the requirement for prior authorization was dependent on a case-by-case basis — if a patient’s case fit the plan’s clinical guidelines for medical necessity, prior authorization “may” not be necessary.

Clinical Guidelines

Determining “if” a plan requires prior-authorization is a preliminary step along a path doctors say is riddled with road blocks.

“I think the thing that’s most maddening to practicing [doctors] is that we usually know whether we’re going to get the prior authorization approved or not, but it’s still going to require all these hoops to jump through and all this time,” said Dr. Charbonneau, the Montana family physician.

Requests are reviewed by a patient’s plan for general coverage and whether the plan deems the test or procedure necessary for the patient’s condition.

While a patient’s doctor may think what they’ve ordered is appropriate care, the insurance company may disagree — particularly in the initial consideration of a prior authorization request.

“I have lots of examples,” Charbonneau said.

One of those examples was a male patient who, as a 90-pack-per-year smoker, had a high risk for lung cancer. A computed tomography (CT) scan to screen for cancer showed nodules and a suspicious mass in the man’s lungs, and the radiologist who reviewed the scan recommended the patient receive a follow-up scan a month later.

When Charbonneau put in the prior authorization request for the second CT, including the patient’s chart with notes from the radiologist, it was denied.

“The insurance company said, ‘You can’t order another CT, you just did one a month ago,’ and I’m like, ‘Well, pretty clearly, you did not have all the information that I had,’” he said.

He appealed, instigating the next stage of the prior-authorization process called a “peer-to-peer” review, where a patient’s doctor can make his or her case to a doctor employed by the insurance company for why the test or procedure is medically necessary.

“As soon as I started telling the doctor doing the peer to peer: 90-pack-year history, this is what the scan looked like before and why we’re concerned about it, and what the radiologist recommendations were, he was like, ‘Oh, of course, we’re going to cover that,’” Charbonneau said.

But while that case was resolved in the patient’s favor, he said it’s demonstrative of the roadblocks doctors are constantly facing because of prior authorization.

“It wasn’t a surprise that it needed to happen, but we still had to go through those hoops,” he said.

Those hoops — such as the need to go through an appeal process and peer-to-peer review — are the driving force behind what critics say is a core negative consequence of these policies: delays in care.

“There are just so many conditions where our treatments are expensive and necessary to keep people functioning, if you delay or deny those things and don’t have something in place that works to take care of that person, you’re going to potentially create a really big problem,” Dr. Charbonneau said.

A really big problem — such as Kathleen Valentini’s aggressive sarcoma that required radical amputation to treat.

The Valentini family has alleged, both in interviews with InvestigateTV and in court filings, that Kathleen’s MRI getting delayed because of the prior authorization process directly affected her cancer treatment plan.

The American Medical Association agreed with the family, submitting an amicus brief in support of their claim along with other medical groups, and publishing an article titled, “Cancer killed Kathleen Valentini, but prior auth shares the blame.”

According to the 2022 AMA survey, the experience described by the Valentinis is a shared one: 94% of physicians reported prior authorization at least “sometimes” delays their patients’ care, and 89% of physicians said the prior authorization process had a negative effect on patient health outcomes.

One in three reported prior authorization complications has led to a “serious adverse event” for a patient in their care, a quarter said a patient has ended up hospitalized, and 9% of respondents said they’ve had a patient become permanently disabled or die because of the process.

“It’s very hard for anyone to make the case that the current situation with prior authorization is working,” Charbonneau said.

‘Evidence-Based’

Insurance companies’ rationale behind prior authorization policies is “to help patients get the right care, at the right time, in the right setting,” Matt Eyles, president and CEO of America’s Health Insurance Plans (AHIP), the primary trade and lobbying association for the industry, said in his 2018 testimony to Congress.

Despite multiple attempts by InvestigateTV to schedule an interview, AHIP refused to make someone available to respond directly to criticisms about prior authorization, instead sharing the organization’s published literature on the topic.

In his opening statement to the Senate Committee on Health, Education, Labor and Pensions, Eyles gave an overview of the industry’s argument:

“We work with clinicians to help confirm treatment regimens ahead of time and ensure the use of the most cost-effective therapies. Prior Authorization is one example of an effective medical management tool to ensure better smarter care,” he said in his remarks.

AHIP asserts prior authorization is applied to a small percentage of services covered by insurers, and that the process has been effective in addressing “overuse and misuse” of tests and procedures by verifying care is provided in an “appropriate setting” by a “qualified” provider.

“With prior authorization, our members analyze whether a treatment is safe and effective for a particular patient based on the best available clinical evidence,” Eyles continued in his testimony, adding that AHIP is working with others in the health care space to increase efficiency and otherwise improve the process.

AHIP has conducted its own surveys on prior authorization over the last few years, polling its member companies about their use of the utilization management tool.

Some of the survey questions addressed the big-picture criticisms of prior authorization.

For example, in a 2019 AHIP survey of 44 insurers, plans were asked to note the reason behind denials of prior-authorization requests.

“Incomplete clinical information to support authorization request” and was the most common reason given for initial prior authorization denials.

For final denials, the most common reason was “Requested procedure/medication is not clinically appropriate for the patient based on medical literature or clinical guidelines.”

Clinical appropriateness — otherwise known as medical necessity — and how insurers define it is one of the primary sticking points for critics of the current prior authorization landscape: Roughly 31% of AMA survey respondents in 2022 said in their opinion, insurer’s prior-authorization policies are “rarely” or “never” what they consider to be “evidence-based.”

Insurers, on the other hand, unilaterally disagree, with respondents to AHIP’s 2022 prior authorization survey citing a variety of evidence-based resources their plan uses to determine clinical guidelines.

Still, InvestigateTV found the fine-print of health plans sometimes indicates “evidence-based” is not necessarily a fixed term.

When reviewing Anthem-BCBS policies and guidelines for utilization management (UM) — a blanket term for processes like prior authorization — the website requires visitors acknowledge not only that evolving technology means guidelines are subject to change but also:

“These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline.”

AHIP has publicly said the insurance industry is working to improve the process without affecting quality. One of those improvements, the association said, is the development of web-based portals for submitting requests.

But in a publication sent to InvestigateTV by AHIP, the insurance lobby said doctors’ offices are “lagging” in adopting their end of electronic submission programs.

Charbonneau, the Montana physician, said automation and advances in electronic health records can have the best intentions but still be cumbersome.

He gave the example of putting in a prior authorization request for a particular antibiotic, only to get a response from the patient’s insurer denying his request then recommending the very same medication.

“I saved it because I still don’t know how it happened,” he said. “My nurse actually brought it to me and she’s like, ‘Am I reading this right?’ … So it says: This medication is the one that’s denied. This is the medication that’s recommended. But aren’t they the same thing?’ and I was looking at it, [and] I’m like, ‘Yeah, they are. Exactly. They’re exactly the same thing.”

He said it’s the kind of thing that may have been missed by a system of automated responses, or those being processed at the initial stage by employees without much medical experience.

“I think we need to embrace all kinds of workers in healthcare, but it is important the level of experience and training that you have,” Charbonneau said.

InvestigateTV found numerous examples of job listings for prior authorization processing jobs with minimal needed requirements.

For a “Utilization Management Representative I,” position at Elevance Health, the only required qualifications are a High School diploma or GED and a minimum of 1 year of customer service experience.

The role description notes the employee would not be making clinical decisions and would refer cases “requiring clinical review to a Nurse reviewer.” However, the description states the employee would also conduct a “clinical screening process” and “determine contract and benefit eligibility” — and there is no requirement that a candidate have any experience involving healthcare.

“I think [job listing example like that] is exactly how we were able to get that fax that said, ‘This antibiotic is both denied and approved at the same time,’” Charbonneau said. “I mean, if it had been someone with any medical experience whatsoever, there’s no way that fax would have even been sent.”

Online resumes also show a lack of medical experience for the first-line employees working at insurance companies. For example, prior to taking a preauthorization job, InvestigateTV found employees whose immediate prior job experiences included working as a hardware store clerk and as a services representative at a ranch.

‘I just felt terrible because I couldn’t do anything’

Justin Williams, who now has a 14-year background in health insurance, used to be one of those first-line employees.

Williams posted a video to TikTok in response to a creator asking users to “share a company secret that you can share because you don’t work there anymore” describing his time as someone responsible for the initial processing of prior authorization requests.

“The whole prior authorization process is designed to take as much time as possible,” he alleges in the short clip, going on to say: “It’s all a roadblock designed to save the company money.”

Williams said in an interview with InvestigateTV that he bases his statements in the video on his time as a “Utilization Management Representative” for Anthem, which has since rebranded to Elevance Health.

His primary job was to process the prior authorization requests that came into his unit as electronic “faxes,” — looking up the customer’s insurance plan and routing the request to a nurse for review.

Over time, however, he said an additional task was added to his team’s workload: Making calls to customers to educate them on various health-coaching programs offered by their plan designed to steer them away from high-cost care like the emergency room and answering return calls about these programs to connect members to coaches.

Eventually, he said these coaching calls began to eat into his and his colleagues’ ability to get through the queue of waiting prior authorization requests.

“You’d spend all your time on these calls, and we’d have no time for faxes,” Williams said. “So we would go into like the weekend, sometimes with like literally thousands and thousands of faxes in our system that didn’t have a home yet.”

In what he referred to as “gallows humor,” he said his team would jest about aiming to get the balance of waiting electronic faxes down from more than 3,000 to a number equivalent to whatever calendar year it happened to be.

Insurance plans typically give a window for the maximum processing time for requests depending on what type of request is involved. Many commit to a decision being made in 10-15 days, which is the legally-required timeframe in many states, and was generally the case where Williams worked.

He said he felt like the company was prioritizing coaching calls over faxes, which made it difficult to manage them and pushed the responses to the end of the timeframe.

“It basically became clear to me that the primary function of the insurance company was not so much getting things done in a timely fashion,” he said.

He said his team also fielded calls from providers attempting to check-in on their prior authorization requests or expedite them — some of them from doctors urgently trying to get approval so their patients could get the care they needed — but Williams said he had few options to provide any kind of assistance.

“We would have desperate providers calling in saying, ‘I need to talk to the nurse working on this, I need to talk to whomever,’ and we would just have to get them over to provider service line, which was pretty hostile. It didn’t actually usually have like a way for them to actually speak with somebody … or just getting them into somebody’s voicemail,” he said.

Eventually, Williams said he felt he could no longer work under the conditions he said he was experiencing.

“It was very frustrating,” he said. “We are told that we want to care about what we do, and we are told we have to do a good job, but the culture doesn’t support that.”

InvestigateTV contacted Elevance Health about Williams’ experience and the job listings similar to his, and received an email response from a spokesperson:

Utilization Management Representatives play an essential role at Elevance Health in taking inbound questions from providers ensuring prior authorizations are routed to our nurse and physician reviewers to determine whether health care services requested are medically appropriate based on many health and safety factors in the case presented. Our utilization management team receives regular training to assist them in managing the intake of prior authorization requests. This role is focused on taking in information for prior authorization from providers and, in some cases, assisting members in navigating and accessing the right resources. The utilization management team coordinates the request, but these associates are not authorized to provide clinical guidance, assessments or evaluations.

Our teams ensure prior authorizations are reviewed in a timely manner and regulators regularly review and have approved our process for prior authorizations across the country. The vast majority of our prior authorization requests, 95%, meet or beat the National Committee for Quality Assurance (NCQA) or our additional internal standards for turnaround times. Our nurse and physician reviewers consider the medical information provided and do not have access to cost information when reviewing requests. In addition, we’ve also created programs that help us automate and speed up the prior authorization requests.

Standard of Care

Kathleen Valentini had been referred to an orthopedic doctor after the physical therapy and over-the-counter medication prescribed by her primary care physician had failed to help with the increasing pain in her right hip — pain that was beginning to limit her ability to walk.

The initial denial for an MRI the doctor requested was based on a determination by eviCore, a third-party prior-authorization contractor used by EmblemHealth, that the scan was not medically necessary.

That determination, the denial letter dated Feb. 16, 2019 stated, was because Kathleen had not demonstrated that alternative treatments including physical therapy and medication had failed to alleviate her pain.

“When they denied it, they asked that she do physical therapy first, but they just paid for physical therapy,” Val Valentini said.

That initial denial and the weeks-long wait during the appeal process, led the Valentini family to sue the insurance company and its third-party contractor eviCore for negligence and medical malpractice.

They alleged the insurance company’s decision to initially deny authorization for the MRI on the grounds of Kathleen needing to complete physical therapy was negligent.

“There’s a direct causation,” said Steve Cohen, the Valentinis’ attorney in the case. “They practiced medicine, and they were negligent. They delayed the diagnosis. And as the doctors at Sloan Kettering said, and as our experts have said, that delay caused the delay in diagnosis, and importantly, the delay in treatment, and thus her suffering.”

Further, the Valentinis’ case argued the insurance company — by issuing decisions that influenced the timing and course of Kathleen’s care — was practicing medicine and therefore should be held to a standard of care the same way a physician would be.

“At some point, somebody has to be held accountable,” Val Valentini said. “If a doctor did something that was incorrect, or caused pain and suffering, that’s what happens. Police officers are sued, you know, everybody is sued because that’s the way you hold them accountable.”

In response to an inquiry about the Valentini case, a spokesperson from EmblemHealth said by email: “Due to HIPAA privacy laws, we cannot discuss or share information about the Valentini case.”

EviCore also declined to discuss the case directly, but sent a statement by email as well:

“We care deeply about the health and well-being of patients, and while we can’t comment on the details of the litigation, we can affirm that our work is designed to ensure that patients receive care grounded in the latest clinical evidence as quickly and seamlessly as possible.”

While they didn’t provide comments to InvestigateTV, the companies did file responses in court, moving for dismissal.

A New York district court judge dismissed the Valentinis’ case, in part because there is no law in the state that holds insurers or their sub-contractors to a “duty of care.” The family appealed a portion of the case, but the appeals court upheld the dismissal.

“I had hoped that they would come out with a different decision closer to what we believed, but they didn’t,” Cohen explained after the February ruling. “And they said: ‘this particular set of circumstances since there’s nothing in the statute, and there’s no case law surrounding in health insurance companies or utilization review companies, we are not about to make new law,’ it had to be very narrowly constrained.”

The court’s ruling, in part, hinges on a distinction insurance companies themselves make in their fine-print: That denial of authorization only means the insurer won’t pay for the test or procedure, and that the patient and their doctor have the ultimate say-so in what care is received.

However, research from multiple sources shows that if an insured patient’s plan denies coverage, the patient is very unlikely to pursue that care.

According to the AMA’s 2022 survey, 80% of physicians said the prior authorization process at least “sometimes” leads to patients abandoning care, and 26% reported this occurs “often.”

The Commonwealth Fund, a private research firm focused on health care quality and equity, found in its biennial health survey that regardless of their level of health insurance coverage, 31% of adults have foregone a recommended test, treatment or follow-up appointment because of out-of-pocket costs.

Back in Montana, Dr. Charbonneau said it’s not a hypothetical problem, not only because of fear of costs, but because patients assume there’s no way around a denial.

“A lot of [people] think that like when you hear ‘No,’ that that’s the end,” he said, “and that’s, I think, a pretty normal human experience. If someone in authority says ‘No,’ they must have a good reason for it.”

For Cohen, the fact that denial of a prior authorization can even theoretically alter a patient’s treatment plan means insurers are, for all intents and purposes, practicing medicine — and should be held accountable accordingly.

“There are laws for doctors, dentists, nurses, hospitals, but not for insurance companies, and that’s got to change,” he said. “They need to be held accountable when they make mistakes like this.”

In the absence of laws on the books, Cohen said the ruling in the Valentini case concerns him, because even though the decision doesn’t create a legal precedent, it could guide other courts in similar cases.

“I think it sends a very clear message in terms of the quality of care that people will receive — that insurance companies … they can do what they want,” he said.

Further complicating things, the Valentinis’ insurance plan was not subject to the Employee Retirement Income Security Act of 1974 (ERISA), which gave them a wider latitude to sue their insurance company in the first place.

For most people whose insurance is provided by their employer, a U.S. Supreme Court ruling in the early 2000s greatly limited both a patient’s ability to sue over actions of a health insurer and the ability of states to pass legislation about health insurance liability, because ERISA pre-empts any state action.

Still, laws surrounding prior authorization and other utilization management aspects of health insurance coverage in general do exist in most states, including in New York where the Valentini case was tried, but fewer than half have requirements for who reviews prior authorization requests, and only 17 have language about clinical guidelines. New York’s statute has neither.

The American Medical Association, which had supported the Valentinis’ case, is pushing for further efforts to address prior authorization and has made it an advocacy priority — particularly when it comes to holding insurers accountable.

“The AMA supports the development of legislative initiatives to assure patients have access to the criteria or rationale used by their health plan for utilization review to determine the necessity and appropriateness of health care services, and to assure that health insurers take responsibility when patients are harmed due to the administrative requirements of the plan,” the association said in an emailed statement.

There have been efforts at the national level to address holding health insurance companies accountable: In 2021 Democrats in the House of Representatives introduced the “Justice for Patients Act,” which would limit forced arbitration by insurers, and the Centers for Medicare & Medicaid Services is working through a rule making process for certain kinds of health plans that starting in 2026 would require an answer to prior authorization requests within seven days, among other things.

Also on Capitol Hill, prior authorization policies of insurers who provide Medicare Advantage coverage would have been further regulated by the Improving Seniors’ Timely Access to Care Act of 2022.

An investigation by the Office of Inspector General for the Department of Health and Human Services found instances where companies denied prior authorizations using guidelines outside of Medicare rules. They also found cases errors made by companies during the claims process led to denial of care.

The Seniors’ Timely Access to Care Act failed to move through the Senate before the end of the last congress, but Charbonneau, whose group Medicine Forward advocated for passage of the bill, said even if the legislation were to be passed, it will take much more to address what faces the commercially-insured.

“We have to come together and say like we are advocating for human interests,” he said, referring to a collaboration between the medical community and insurance companies. “And maybe we’re not going to get like the whole win at once, but like a series of small wins that continue to build that push us towards this more human future. That’s what we want to fight for.”

Val Valentini said the court’s ruling on his lawsuit was “disappointing, to say the least,” and he said he doesn’t have a lot of faith that Congress will address the issue.

Still, by sharing his wife’s story, he said at least the public may get a look at the inner-workings of a system he says is terribly broken.

“What they’re doing is disgusting,” he said, “and it’s getting worse and worse, it seems.”

Conner Hendricks contributed to this report.

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