OK, we admit it. We’re (fairly) snarky when it comes to health insurance companies. But there’s no room for snark when it comes to a recent Medscape article, which follows the journey of North Carolina patient Kathleen Valentini.
Valentini consulted an orthopedic surgeon after experiencing excruciating pain in her hip that only continued to worsen. When an X-ray failed to reveal the cause of Valentini’s pain, the surgeon ordered an MRI.
Valentini’s insurer – Group Health Inc (GHA) – denied coverage of the MRI (surprise, surprise), saying that it was “medically unnecessary.” The insurer stated the MRI would only be medically necessary if Valentini failed to improve after six weeks of physical therapy, according to federal court documents available on PACER.
Right, because health insurers — whose business is paying for care, not providing it — should be determining what is medically necessary.
Of course, the orthopedic surgeon immediately appealed the insurer’s denial. Not only was the MRI necessary, the surgeon argued, but Valentini had also already completed a full course of physical therapy ― which the insurer had already paid for.
Nearly 40 days later, GHI reversed its denial.
That fought-after MRI revealed sarcoma — cancer that starts in the bones and soft tissues — in Valentini’s right hip. Physicians at Memorial Sloan Kettering in New York gave the Valentini family the grim news: Had she come to them a month sooner, they said, oncologists could have proceeded with chemotherapy alone, but physicians would now have to amputate Valentini’s leg, hip, and pelvis.
Doctors continued their testing, and later found that the cancer also spread to Valentini’s right lung. Two years later, Valentini passed away.
The Valentini family is suing, and rightfully so. The lawsuit contends that GHI’s claim denial and delayed (and unnecessary) prior authorization for the MRI prevented physicians from catching the cancer in time.
Valentini’s story is nothing short of tragic. It’s also, unfortunately, not uncommon. Here at Un-covered, we’ve seen health insurers manipulate prior authorizations to the detriment of patients’ health and safety, over and over again.
So, does anyone really believe that prior authorizations benefit anyone other than the insurance company’s bottom line? Doctors certainly don’t: Ninety-three percent of physicians report that prior authorizations delay access to necessary care, according to a 2021 survey by the American Medical Association (AMA).
How many patients will have to die before we do something about it?