A system designed to wear people down: If someone with my knowledge and connections struggles to get a basic test approved, imagine what the average patient goes through.
The amount of prior authorization hellscape I deal with to get the rare disease drug required for my survival has radicalized me and turned me into an advocate. This system has to go.
Agree with this 👆 100%. Watched multiple pediatricians quit in my children’s pediatric practice when the industry suddenly decided to take Flovent off the formulary. Why? Their entire practice was reduced to prior authorizations for children with asthma who otherwise would be pay $400/month for the only approved pediatric controller medication. As an RN I feel compelled to shout this from the rooftops. The insurance company doesn’t even know why they deny, delay, and refuse to pay at this point because that entire decision process has been outsourced to a for profit company running proprietary AI based profit optimization algorithms off actuarial data…
It's bananas. Even today- a drug that leaves my system and exposes me to a flare, the insurance company requires me to wait until the day I technically need it to be safe to even approve its use. It's so dangerous.
I live in Oregon and we are aiming to submit a single payer Universal Healthcare Plan to our legislature by September 2026. My frustration with navigating health insurance throughout my cancer treatment has motivated me to join the advocacy group Health Care for All Oregon. If change won't happen at the federal level, hopefully we can get it done at the state level! https://www.hcao.org/.
My son-in-law has EGPA. He was in a trial and was taking Nucala (as we came to find out). The trial ended and it took 1-1/2 years to get back on Nucala, and involved his lawyer aunt who used to work for BCBS (his insurer) to get involved. Several times we didn't know if he was going to survive. He was living on steroids, pills and inhalers. The current system radicalizes people like Luigi Mangione.
This is an area that Health Care Un-Covered could look into, in my opinion. If people are in studies, and the medicine is found to be valuable, shouldn't there be some sort of guarantee that people will have access to the medicine afterwards, no matter whether the patient got drug or placebo? They do studies in other countries, like the UK, the EU, and even China. How does this work out for patients in studies in those countries?
As a health care lawyer who represents patients and clinicians in disputes with health insurance companies, this story is all too common. I agree with Mr. Glickman's suggested reforms, but there also is an inherent problem in that a patient who receives insurance through a private employer cannot sue an insurer from damages arising from a wrongful denial, even if in bad faith. These claims fall under the Employee Retirement Income Security Act ("ERISA"), which limits the recovery to the benefits that should have been paid in the first place. As a result, few lawyers will take on such a case, and insurers have the incentive to deny, knowing that, at worst, they may be forced to pay some small portion of what they actually owe. Moreover, of the hundreds of millions of denials every year, less than 1% appeal, because they are intimidated or don't know what to do. There are too few resources to help individuals to fight back against the for-profit health insurance industry. I'm trying to help by setting up pro bono services with law students to assist individuals with appeals, but there is a long way to go. https://healthinsuranceappeals.org/
The way to get something approved is to have your Milliman or your Interqual request up and hope that your diagnosis is not on the escalation list for medical director review. Also you hope the nurse documenting the review isn’t bogged down by a high metric because the faster she gets that review to the medical director the faster she gets to make her numbers. As of 2024 there were 124 diagnosis on the list. The preauth team which they keep laying off and mostly have outsourced to other countries usually don’t begin the auth till 3 days before it’s about to expire on a 14 day request. Then hopefully your request is not denied on something entirely not related to your case. I once escalated a review for bilateral prosthesis due to member had lost a lot of weight and recent new amputation. This member was young person in their 50’s. He just happen to be at a skilled nursing home trying to get rehab but could not get a good fit on his existing prosthesis making it unstable for him to stand. The medical director denied the new prosthesis based on that he lived at a nursing home. First he lived at home and even if he had lived in a nursing home he still had the right to walk. I advocated for this man and got one of the Transition MD’s to call this doctor. Also the nurse reviewer left out key parts of his documentation. I believe she did this on purpose.’it took over a week to correct this. Not everyone at the plan can have this kind of oversight as there are tons of denials, some say denied for a specific reason when the very thing it was denied for is right there in the medical record. Stated clearly that it exists. Than you know that the plan has targeted that test or diagnosis for denial.
The challenges of our healthcare system are insurmountable. I am a CCRN, Hospital Admin and Executive Consultant and witness the “process”!issues every day!!! These issues are from our Federal Government, Insurance companies, Pharmaceutical companies and Physician practices. Imaging delays of up to 4 months, medication that requires PAs which delays treatment and may require ED visits, cost of medications without a PA in excess of $787. The list goes on.
unfortunately, sociopathy affects most voting public. Nothing will be corrected until the voting public changes. They call it "individualism". "Good for me, but not for you".
I am primary care doctor in a NYC public clinic. We are understaffed and have 20 minute appts for new patients and for regular, vey sick patients often with triad of high blood pressure, diabetes and chronic kidney disease. We often need translators which slow down the visits. Prior authorization (PA) has exploded. Many patients with limited insurance or Medicare Advantage are hit hard with PA. The stress on medical staff is high and the health insurance companies ignore patients’ health to give shareholders and themselves huge amounts of money. We need public health care for all and the elimination of rich profit driven private insurance empires.
Thirty-five years ago when I was working on the first state-based single payer bill, I had many discussions with Canadian health administrators and physicians. In those days with much less computer capacity, the provincial health authorities were able to see which physicians were doing inappropriate and excessive test ordering and had "chats" with them. So I am glad Dr. Glickman recommends seeking easily reachable data on the malefactors rather than proactive PA BS on everyone. I also believe that many of the high-tech imaging procedures are way overcharged in the US. Certainly, international price comparisons suggest that. As Uwe Reinhardt said decades ago, "It's the prices, stupid."
Infuriating! What a waste of your time, your provider's time, etc. etc. Perfect example of why admin costs are about 25% of our $4+ trillion per year healthcare spend!🤬
You continue to amaze me. - - - Your struggle to get PA misstates the issue. Because: 1.) ONLY your doctor has the LEGAL standing to determine the care you need, 2.) The in-network provider is REQUIRED to provide that care regardless of what your insurer decides on coverage, and 3.) The bill for the care is a matter to be resolved soley between the provider and the insurer. But then I belive you know that.
The real issue with PA is that providers are CONTRACTUALLY required to provide the needed care regardless of whether the insurer agrees to pay for it/cover it. However, since patients are never told this SECRET fact, insurers can simply hold the cost of the care over a provider's head and run out the clock, while a patient tears his or her hair out waiting. - - If I'm wrong, I'd love to have you explain where. Frank Lobb at <killAbill.com>
Seth, PA is one procrastination strategy they use. The other is Step Therapy, denying a course of treatment and requiring a lower cost alternative be tried first. They do try that with Diagnostics too, a bit like they did with your ERCP Ultrasound recommendation.
Wendell Potter recently addressed this using several comments including my son’s case to illustrate the absurdity of these delaying tactics. Not my Substack article, but you can find it here:
Also the madness of the insurer being able to determine when the clock starts is the same stuff the airlines used to get away with by closing the doors and pulling back the air bridge and calling that a departure, even if they sat on the stand or on an Apron for hours after. The regulators HAVE to apply the rules they already have, and if they are not enough, introduce stronger regs.
The biggest issue is the patient is not a customer. Accordingly they have no power in the entire dynamic, even less when, as you say, don;t have our professional/semi-professional knowledge of the business.
Very enlightening article on an issue that is affecting patients nation-wide. Of note, yesterday (8/25/25), Johns Hopkins Medicine sent a notice to patients that their providers will no longer be a part of the UnitedHealthcare (UHC) network, after negotiating with UHC for 8 months to change their ways. JHM cited UHC’s frequent use of pre-authorizations and care denials that is delaying critical treatments for patients. I am encouraged that a prestigious healthcare institution like Johns Hopkins has taken action, but dismayed that many of my wonderful JHM providers will be out-of-network.
United will pretend to cave in on some of their requests. Than they will happily sign the new contract thinking they accomplished some kind of change. United will announce that they negotiated and look like they put the members first even though they had to give up on the cost making the md’s and John Hopkin’s the bad guys. Meanwhile back at the drawing table they will have allready instructed everyone how to circumvent that new contract.
The amount of prior authorization hellscape I deal with to get the rare disease drug required for my survival has radicalized me and turned me into an advocate. This system has to go.
Agree with this 👆 100%. Watched multiple pediatricians quit in my children’s pediatric practice when the industry suddenly decided to take Flovent off the formulary. Why? Their entire practice was reduced to prior authorizations for children with asthma who otherwise would be pay $400/month for the only approved pediatric controller medication. As an RN I feel compelled to shout this from the rooftops. The insurance company doesn’t even know why they deny, delay, and refuse to pay at this point because that entire decision process has been outsourced to a for profit company running proprietary AI based profit optimization algorithms off actuarial data…
It's bananas. Even today- a drug that leaves my system and exposes me to a flare, the insurance company requires me to wait until the day I technically need it to be safe to even approve its use. It's so dangerous.
This sounds so much like the definition of the cycle of abuse—just applied on a macro scale.
totally abusive.
Take care, yes this system of confusion is by design of crooked lobbyists bought & paid for by for-profit private health insurance industry
I'm a pitpull. I even wrote a play-by-play of how to navigate the denial process for folks. https://taylorcoffman.substack.com/p/stages-of-denial
I live in Oregon and we are aiming to submit a single payer Universal Healthcare Plan to our legislature by September 2026. My frustration with navigating health insurance throughout my cancer treatment has motivated me to join the advocacy group Health Care for All Oregon. If change won't happen at the federal level, hopefully we can get it done at the state level! https://www.hcao.org/.
My son-in-law has EGPA. He was in a trial and was taking Nucala (as we came to find out). The trial ended and it took 1-1/2 years to get back on Nucala, and involved his lawyer aunt who used to work for BCBS (his insurer) to get involved. Several times we didn't know if he was going to survive. He was living on steroids, pills and inhalers. The current system radicalizes people like Luigi Mangione.
This is an area that Health Care Un-Covered could look into, in my opinion. If people are in studies, and the medicine is found to be valuable, shouldn't there be some sort of guarantee that people will have access to the medicine afterwards, no matter whether the patient got drug or placebo? They do studies in other countries, like the UK, the EU, and even China. How does this work out for patients in studies in those countries?
Hellacious.
Feels like a race in reverse.
Vote the Republicans out.
As a health care lawyer who represents patients and clinicians in disputes with health insurance companies, this story is all too common. I agree with Mr. Glickman's suggested reforms, but there also is an inherent problem in that a patient who receives insurance through a private employer cannot sue an insurer from damages arising from a wrongful denial, even if in bad faith. These claims fall under the Employee Retirement Income Security Act ("ERISA"), which limits the recovery to the benefits that should have been paid in the first place. As a result, few lawyers will take on such a case, and insurers have the incentive to deny, knowing that, at worst, they may be forced to pay some small portion of what they actually owe. Moreover, of the hundreds of millions of denials every year, less than 1% appeal, because they are intimidated or don't know what to do. There are too few resources to help individuals to fight back against the for-profit health insurance industry. I'm trying to help by setting up pro bono services with law students to assist individuals with appeals, but there is a long way to go. https://healthinsuranceappeals.org/
The way to get something approved is to have your Milliman or your Interqual request up and hope that your diagnosis is not on the escalation list for medical director review. Also you hope the nurse documenting the review isn’t bogged down by a high metric because the faster she gets that review to the medical director the faster she gets to make her numbers. As of 2024 there were 124 diagnosis on the list. The preauth team which they keep laying off and mostly have outsourced to other countries usually don’t begin the auth till 3 days before it’s about to expire on a 14 day request. Then hopefully your request is not denied on something entirely not related to your case. I once escalated a review for bilateral prosthesis due to member had lost a lot of weight and recent new amputation. This member was young person in their 50’s. He just happen to be at a skilled nursing home trying to get rehab but could not get a good fit on his existing prosthesis making it unstable for him to stand. The medical director denied the new prosthesis based on that he lived at a nursing home. First he lived at home and even if he had lived in a nursing home he still had the right to walk. I advocated for this man and got one of the Transition MD’s to call this doctor. Also the nurse reviewer left out key parts of his documentation. I believe she did this on purpose.’it took over a week to correct this. Not everyone at the plan can have this kind of oversight as there are tons of denials, some say denied for a specific reason when the very thing it was denied for is right there in the medical record. Stated clearly that it exists. Than you know that the plan has targeted that test or diagnosis for denial.
The challenges of our healthcare system are insurmountable. I am a CCRN, Hospital Admin and Executive Consultant and witness the “process”!issues every day!!! These issues are from our Federal Government, Insurance companies, Pharmaceutical companies and Physician practices. Imaging delays of up to 4 months, medication that requires PAs which delays treatment and may require ED visits, cost of medications without a PA in excess of $787. The list goes on.
Call me…
unfortunately, sociopathy affects most voting public. Nothing will be corrected until the voting public changes. They call it "individualism". "Good for me, but not for you".
And they complain about the wait times in the Canadian healthcare system.
Baloney!
I am primary care doctor in a NYC public clinic. We are understaffed and have 20 minute appts for new patients and for regular, vey sick patients often with triad of high blood pressure, diabetes and chronic kidney disease. We often need translators which slow down the visits. Prior authorization (PA) has exploded. Many patients with limited insurance or Medicare Advantage are hit hard with PA. The stress on medical staff is high and the health insurance companies ignore patients’ health to give shareholders and themselves huge amounts of money. We need public health care for all and the elimination of rich profit driven private insurance empires.
Their goal is for you to give up, go away, and die.
Thirty-five years ago when I was working on the first state-based single payer bill, I had many discussions with Canadian health administrators and physicians. In those days with much less computer capacity, the provincial health authorities were able to see which physicians were doing inappropriate and excessive test ordering and had "chats" with them. So I am glad Dr. Glickman recommends seeking easily reachable data on the malefactors rather than proactive PA BS on everyone. I also believe that many of the high-tech imaging procedures are way overcharged in the US. Certainly, international price comparisons suggest that. As Uwe Reinhardt said decades ago, "It's the prices, stupid."
Infuriating! What a waste of your time, your provider's time, etc. etc. Perfect example of why admin costs are about 25% of our $4+ trillion per year healthcare spend!🤬
Mr. Potter:
You continue to amaze me. - - - Your struggle to get PA misstates the issue. Because: 1.) ONLY your doctor has the LEGAL standing to determine the care you need, 2.) The in-network provider is REQUIRED to provide that care regardless of what your insurer decides on coverage, and 3.) The bill for the care is a matter to be resolved soley between the provider and the insurer. But then I belive you know that.
The real issue with PA is that providers are CONTRACTUALLY required to provide the needed care regardless of whether the insurer agrees to pay for it/cover it. However, since patients are never told this SECRET fact, insurers can simply hold the cost of the care over a provider's head and run out the clock, while a patient tears his or her hair out waiting. - - If I'm wrong, I'd love to have you explain where. Frank Lobb at <killAbill.com>
Seth, PA is one procrastination strategy they use. The other is Step Therapy, denying a course of treatment and requiring a lower cost alternative be tried first. They do try that with Diagnostics too, a bit like they did with your ERCP Ultrasound recommendation.
Wendell Potter recently addressed this using several comments including my son’s case to illustrate the absurdity of these delaying tactics. Not my Substack article, but you can find it here:
https://open.substack.com/pub/healthcareuncovered/p/being-a-professional-patient-and?r=2vmx1l&utm_medium=ios
Also the madness of the insurer being able to determine when the clock starts is the same stuff the airlines used to get away with by closing the doors and pulling back the air bridge and calling that a departure, even if they sat on the stand or on an Apron for hours after. The regulators HAVE to apply the rules they already have, and if they are not enough, introduce stronger regs.
The biggest issue is the patient is not a customer. Accordingly they have no power in the entire dynamic, even less when, as you say, don;t have our professional/semi-professional knowledge of the business.
Very enlightening article on an issue that is affecting patients nation-wide. Of note, yesterday (8/25/25), Johns Hopkins Medicine sent a notice to patients that their providers will no longer be a part of the UnitedHealthcare (UHC) network, after negotiating with UHC for 8 months to change their ways. JHM cited UHC’s frequent use of pre-authorizations and care denials that is delaying critical treatments for patients. I am encouraged that a prestigious healthcare institution like Johns Hopkins has taken action, but dismayed that many of my wonderful JHM providers will be out-of-network.
United will pretend to cave in on some of their requests. Than they will happily sign the new contract thinking they accomplished some kind of change. United will announce that they negotiated and look like they put the members first even though they had to give up on the cost making the md’s and John Hopkin’s the bad guys. Meanwhile back at the drawing table they will have allready instructed everyone how to circumvent that new contract.