Doctors speak up: The most common patient health insurance challenges

Health insurance coverage in the United States comes with an excessive administrative burden. Experts estimate that insurance-related direct and indirect costs account for approximately 25 percent of the nation’s bloated healthcare expenses.^[]

MDLinx spoke with our psychiatry advisor Amanda Zeglis, DO, MBA, and our oncology advisor Nitin Chandramouli, MD, FACP, to get physician perspectives on the matter.

Third-party pre-authorization headaches

In Dr. Chandramouli's experience, obtaining insurance authorizations can be complex, partially due to the high costs of some treatments. 

“A lot of the treatments we use in hematology and medical oncology are quite expensive, and it does make some sense for insurance companies to ensure that regimens and drugs are being used appropriately as it pertains to the standard of care, as well as by accepted guidelines,” he says.

“In the past, for the ‘big’ insurance companies, it was fairly straightforward to have a conversation with their medical directors to justify treatments, though that still took time. As a practice, we pre-authorize everything.”

Within the last decade, insurance companies have shifted to contracting third-party vendors to manage pre-authorizations, according to Dr. Chandramouli. He notes that these third-party vendors (AIM, Evicore, and etc.) are primarily the ones handling pre-authorizations for imaging, radiation treatments, and systemic therapies for malignancies.

“They have easily made the whole process of obtaining insurance pre-authorization exceedingly difficult on several levels,” he says. “If I could fix one problem with insurance pre-authorization, it would be to eliminate these third-party pre-authorization companies.”

Disagreements on established guidelines

“Frequent denials became common for both regimens and supportive medications (such as anti-emetic pre-meds), forcing the physician to write appeal letters and perform peer-to-peer phone calls in order to obtain pre-authorization,” Dr. Chandramouli explained.

“Denials were also rapid, and certainly suspects of algorithmic processes. In fact, it was of no surprise to many of us when news broke of Cigna denying claims at an inhuman pace using algorithms," he says.

“But here, these third-party pre-authorization companies tried to limit what they would approve using their own version of narrowed pathways/approved regimens,” he added, noting that physicians follow FDA approval and NCCN guidelines to guide their therapies—the latter of which is the wholly accepted treatment guidelines for nearly all cancers that hematologists and oncologists follow, according to Dr. Chandramouli. 

“Yet, I've previously heard directly from the medical director of one of these pre-authorization companies that they felt NCCN was too broad and they were going to narrow the accepted regimens/drugs,” he said. “Many of us found it ludicrous that they felt they had the authority to limit what were acceptable regimens for certain cancers.”

Dr. Zeglis also notes that standards of care guidelines (such as Interqual and Milliman Care Guidelines) identify “what the likely course of treatment should be,” based on a specific diagnosis or how a patient’s symptoms are presenting.

“Frequently, the discrepancies between a treatment plan ordered for a patient and the insurance coverage of that ordered plan are within the provided documentation,” she says. The issue arises when there is not sufficient documentation about these discrepancies, resulting in the insurance company finding the plan is “unnecessary.”

Time wasted with approval delays

“Time has become a huge problem,” Dr. Chandramouli shared. “Medical oncologists are frequently needing to appeal and perform peer-to-peer calls to get treatments approved. This takes time out of the day when time is already a precious commodity best used in patient visits and interactions."

“It was extremely difficult to get any peer-to-peer calls to happen after clinic hours, forcing me to take the time in the middle of clinic to perform these,” he said. This resulted in clinic delays and other patients having to wait longer to see their physicians. The time spent on waiting for pre-authorizations also delays when patients are able to start their regimens, according to Dr. Chandramouli.

“Those who had advanced cancer and were getting palliative treatments to at least help their systems had to wait longer and suffered from their symptoms. Those whose treatment was for curative intent also were forced to wait,” he said.

Advice for clinicians

Dr. Zeglis noted challenges related to skyrocketing healthcare prices and the difficulties in coordinating a patient’s treatment regimen in accordance with th

eir insurance coverage. “While these challenges can create an added hassle for both patients and providers, it is the current state of the industry and must be navigated with care,” she advised.

“Either way, as providers, it is our job to advocate on our patients' behalf in order to find the best compilation of treatment options that are affordable with respect to their specific insurance coverage.”