By Michelle Crouch
Kathleen Valentini was 47 when she first noticed a nagging pain in her hip. The Waxhaw mom tried physical therapy, but her pain just got worse. Her doctor ordered an MRI to find out what was going on, according to court documents and Kathleen’s husband, Val Valentini.
But Kathleen’s health insurer wouldn’t authorize the MRI, a scan that can cost as much as $8,000. After considering the request for two weeks, the insurer said the procedure wasn’t “medically necessary,” her husband said. It ordered her to try six weeks of physical therapy first.
Kathleen already had done that, however. The insurance – which came from her husband’s former employer, the N.Y. City Police Department – even covered it.
“They didn’t bother to review their own records,” Val said.
The Valentinis appealed. Four weeks later, 41 days after the doctor first sought an MRI, the insurer reversed its decision.
When Kathleen finally had the MRI in March 2019, it revealed an aggressive type of bone cancer. Kathleen went to Memorial Sloan Kettering Cancer Center in New York for treatment. The doctors said they needed to amputate her leg, hip and pelvis.
Then they said something that was almost more devastating, Val said: that if Kathleen had come in even a month earlier, they probably could have treated the cancer using only chemotherapy.
Kathleen underwent the amputation and had several rounds of chemo. It wasn’t enough to stop the cancer. She died in November 2020.
“I’m convinced that the delay caused her death,” Val told The Charlotte Ledger/N.C. Health News recently. “They deny and delay and hope you go away.
“It is just wrong.”
Law would create new rules for insurers
Kathleen’s case is extreme, but it underscores why many patients and doctors are frustrated with the process insurance companies use to decide whether to pay for specific treatments. It’s called “prior authorization” or “utilization review.”
Now, North Carolina lawmakers – along with those in about two dozen other states – are considering changes to overhaul that process. The legislation includes time limits that require insurance companies to act faster.
Prior authorization is supposed to prevent doctors and hospitals from recommending expensive and unnecessary procedures. But doctors say prior authorization can keep people from getting life-saving treatments and drugs, sometimes without explanation.
“Doctors are frustrated,” said Chip Baggett, CEO of the North Carolina Medical Society, which is advocating for the legislation. “They go to school to be trained to pick the best therapy for their patients, and someone else from far away is deciding whether their best medical judgment is right.”
Sometimes, he said, the person making the decision for the insurance company is not a physician. Other times, they have no expertise in the medical specialty in question.
About 94 percent of physicians nationwide report delays in care associated with prior authorization, according to a 2022 survey of 1,001 physicians conducted by the American Medical Association. And 1 out of 3 doctors in the same survey say it’s led to serious medical problems for patients.
Health insurers: Prior authorization helps patients
Health insurers say prior authorization protects patients from expensive and unnecessary care, as well as from medical errors.
In a letter opposing the legislation, America’s Health Insurance Plans (AHIP), a national association of health insurers, shared the following examples of ways prior authorization helps patients:
(Prior authorization) can help ensure safer opioid prescribing; help prevent dangerous drug interactions from antibiotics and other infection fighting drugs; and help protect patients from unnecessary exposure to potentially harmful radiation from inappropriate diagnostic imaging, such as CT scans for back pain.
The letter said as many as 1 in 4 prior authorization requests they receive are for care that is not supported by medical evidence.
A spokeswoman for Blue Cross Blue Shield North Carolina declined comment.
Physicians of all specialties say they are spending a growing amount of time trying to persuade insurance companies to approve care, Baggett said. Many doctors have had to hire additional staff just to handle prior authorization reviews, increasing health care costs, he said.
Christopher Tebbit, MD, an otolaryngologist (ENT) with Charlotte Eye, Ear, Nose & Throat Associates, said insurers usually approve his requests for care – but only after he and his staff go through a time-consuming, bureaucratic process. He said he spends several hours on the phone each month in “peer-to-peer” conversations with insurance company reps.
“I’ll say, ‘I don’t know why we are having this call because you’ve approved this same type of procedure for this same type of patient over and over,’” Tebbit said. “It creates a two- to three-week delay in care for no discernable reason, and it takes me away from patients.”
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What the legislation would do
The North Carolina legislation, House Bill 649, is awaiting consideration by the state Senate after unanimous approval by the N.C. House on April 26. Here are a few key provisions of the bill:
- Discussion with the doctor: If an insurer is questioning the medical necessity of a treatment or service, they must notify the patient’s medical provider within five business days and give the provider an opportunity to discuss the decision.
- Time limits for reviews: Insurers must issue a decision about urgent medical services within 24 hours after receiving all of the information about the case and make decisions about non-urgent medical services within 48 hours..
- Only MDs can do reviews: Those who deny or approve medical treatments on behalf of insurers must be actively practicing physicians licensed in North Carolina who have experience in the specialty or treatment in question.
- Physician exemptions: Doctors would be exempt from prior authorization requirements for a particular health care service if they have an 80 percent prior authorization approval rate for that service over the past 12 months. (This is sometimes called a “gold card” law.)
New laws speed up the process
AHIP spokeswoman Kristine Grow expressed particular concern about the physician exemptions. Texas has a similar law, but doctors there need a 90 percent approval rate to be exempt.
“Patients deserve better than doctors who get their care wrong 20% of the time,” Grow said. “We can’t in good conscience support proposals that would give such a free pass on patient safety, efficacy, and value.”
Besides Texas, several other states have approved laws targeting prior authorization rules, and about 20 more are considering legislation, according to the American Medical Association.
In addition, the federal government in April issued new rules for 2024 Medicare Advantage plans. They’re designed to streamline the prior authorization process and require more transparency into how insurers make their decisions.
In recent months, as calls for change have gotten louder, at least three insurers – UnitedHealthcare, Aetna and Cigna – have voluntarily announced that they are making changes to improve their prior authorization processes, according to the The Wall Street Journal.
“We’re not deaf to the complaints out there,” Philip Kaufman, chief growth officer at UnitedHealthcare, told the Journal. “We’ve taken a hard look at ourselves and this process.”
Still denying tests
The Valentinis moved to Charlotte in 2013 after Val retired from the New York City Police Department. Val said he had always heard that the department’s health insurance for retirees, provided by Group Health, Inc. (GHI), was good.
In Waxhaw, Kathleen homeschooled their teenage son, Matthew. In her free time, she loved to bake, and she volunteered at St. Matthew Catholic Church. She also coordinated neighborhood efforts to prepare meals and kits for homeless families.
“She never did anything for herself,” Val said. “She always did everything for everybody else.”
After the amputation, Val said the battles with GHI continued.
“When she was still in the hospital after having a 20-hour surgery to remove her leg, hip and pelvis, her doctor was telling me they were still denying tests,” Val said.
Val and Kathleen filed a lawsuit against GHI in October 2020. Among other claims, the suit alleged GHI appeared “to be engaged in a systemic effort to delay or block necessary medical treatments and services and defeat their contractual obligations.”
GHI’s parent company, Emblem Health Inc., declined comment, citing HIPAA privacy laws.
The Valentinis lost their case in district court, and in February, the 2nd U.S. Circuit Court of Appeals declined to overturn the verdict. In their decision, the appellate judges noted that the insurer never advised Kathleen on a course of treatment, and that insurance reviews do not, in and of themselves, subject patients to physical harm. Rather, they are a service to ensure people are reimbursed for contractually covered medical care.
Ultimately, the judges said, the law “cannot be stretched” to allow the court to hold insurance companies liable in cases such as Kathleen’s.
“The judge said it’s a travesty,” Val said, “but that (the insurance company) didn’t break any law.”
That’s why prior authorization reform laws like the one being considered in North Carolina are important, Val said. They may be the only way to hold insurance companies accountable, he said, and “the system needs to be changed.”