“I was fighting to survive”: Patients still struggle with preauthorization despite promise of reform

Sheldon Ekirch, a 31-year-old resident of Henrico, Virginia, has had a long history of disappointment with her health insurance company, Anthem. However, her world was turned upside down when she received the news that Anthem would finally have to cover the life-changing medical treatment she had been fighting for. For two years, Ekirch had been battling with Anthem to cover the cost of intravenous immunoglobulin (IVIG) infusions, a treatment that could potentially improve her symptoms associated with small-fiber neuropathy, a condition that causes her limbs to feel like they are on fire. Each IVIG infusion costs around $10,000, and Ekirch’s parents had already spent approximately $90,000 out of pocket due to Anthem’s repeated denials.

In February, an external review conducted for the Virginia Bureau of Insurance overturned Anthem’s denial, bringing a wave of relief and tears for Ekirch and her family. The reversal meant that Ekirch’s parents would no longer have to dip into her father’s retirement savings to cover the treatment costs. Despite the emotional rollercoaster, Ekirch described the situation as being in shock but grateful for the outcome.

Anthem spokesperson Stephanie DuBois stated in a prepared statement that IVIG did not align with their evidence-based standards, but they respected the external reviewer’s decision to overturn the denial. This case sheds light on the ongoing struggles faced by millions of patients who have to navigate the prior authorization process with health insurers before receiving necessary medical care. Despite promises of reform from insurance companies, denials remain a frustrating reality within the American healthcare system.

Last June, leaders in the health insurance industry pledged to simplify the prior authorization process by reducing the scope of claims subject to preapproval, promising faster turnaround times and clear explanations of their decisions. However, when contacted by KFF Health News in February, half of the major insurers who signed the pledge failed to provide specifics about the health care services no longer requiring prior authorization.

While some insurers have made specific changes, such as Aetna CVS Health bundling prior authorizations for certain procedures and Humana removing requirements for diagnostic services, skepticism remains among physicians, consumers, and patient advocates. Bobby Mukkamala, president of the American Medical Association, expressed doubts about insurers’ willingness to follow through with voluntary changes, citing past instances where promises of reform fell short.

Patients like Payton Herres and Anna Hocum continue to face obstacles in receiving essential care due to prior authorization denials. Herres, who received a heart transplant in 2012, was denied coverage for her antirejection medication last year by Anthem. Hocum, who battles a rare genetic condition, faced repeated denials for treatment to manage her condition, leading to financial strain on her family and community support through fundraising efforts.

Despite the recent victory for Ekirch in securing coverage for IVIG, her future access to treatment remains uncertain as her COBRA coverage through Anthem expires soon. As she prepares to transition to a new insurance plan, Ekirch is bracing herself for another potential battle with prior authorization, expressing fear and exhaustion at the thought of fighting this uphill battle once again. The road ahead remains uncertain, highlighting the ongoing challenges faced by patients navigating the complexities of the healthcare system.