How prior authorization can kill: a 2-year-old with cancer; a young woman needing chemo; and a 17-year-old in need of a transplant

One of the deadliest practices of Big Insurance is requiring doctors to get approval in advance in many cases before proceeding with treating their patients. It’s called prior authorization. 

Insurance companies know that a lot of people just give up and take a denial as the final word. An untold number of people die because of what essentially are death panels within Big Insurance. 

Do not give up. Be a squeaky wheel or find somebody to be a squeaky wheel for you. Never take a denial as a death sentence you can’t appeal.

Here are two recent stories involving my former employer, Cigna. During my 15 years there, my team and I handled more “horror stories” than I can remember involving patients who had been denied coverage for a potentially life-saving procedure, test, or medication. In many cases, the patient or an advocate for the patient got a reporter or elected official to call us and put us on the spot. And more often than not, the denial would be quickly reversed to avoid bad publicity or annoying a member of Congress or state legislator. 

Cigna denies 2-year-old’s cancer scan

A few days ago, Sandhya Dirks took to Twitter with this heart-wrenching story:

sandhya dirks @audiosand

My baby's cancer may have returned and my insurance, @Cigna, is refusing to help cover a PET scan so we can find out if it has, and if needed, continue our work to save his life. No qualms about putting my child's life on the line for their bottom line. He is not even 2 years old

The tweet quickly went viral. The next day, Sandhya wrote:

sandhya dirks @audiosand

I wrote this last night in anger and pain. I am overwhelmed - in tears - by y'alls response. Heartened by all the support and advice, heartbroken by so many with similar stories. We will spend today trying to get this changed, and will keep this thread updated. THANK YOU ALL

The first tweet got 5.2M views, 47.4K likes, and 9,215 retweets.

In another tweet, Sandhya wrote:

sandhya dirks @audiosand

Some of you asked about a go fund me. Because we live in America, we set one up to cover the bills and many auxiliary expenses of our first, over-a-year long, battle with cancer. I fear we may need to resurrect it, so sharing again now:

gofundme.comHelp Zubin Fraser Dirks Fight Cancer, organized by Cristina KimHello friends and community, As some of you may know, our dear friends Sandhy… Cristina Kim needs your support for Help Zubin Fraser Dirks Fight Cancer

Within hours, Sandhya tweeted this:

sandhya dirks @audiosand

UPDATE: Cigna has approved the scans!!! I appreciate y'all so deeply for making this happen, & Cigna for doing the right thing. But this tweet shouldn't have to go viral for this 2 happen. It's an individual solution to a systemic problem, which is to say no real solution at all.

Cigna denies chemotherapy drugs

On the same day I came across those tweets, I got a note from a different young woman whose mother had reached out to me last June to see if I could help get Cigna to reverse a denial of her daughter’s chemotherapy drugs. As you can imagine, the mother was scared and desperate. Her daughter’s doctors believed the specific chemotherapy drugs they wanted to use were necessary to save her life.

I reached out to a Cigna medical director right away. Within a few hours, he emailed me to say his team would investigate. 

A few hours after that, I got this text message from the patient herself:

In the months that followed, I was afraid to check in with her, fearing the chemo hadn’t worked. And then, a few days ago, I got this beautiful note from her. Now it was my turn to cry — again.

 But you shouldn’t have to know a health-industry insider to convince your insurance company to pay for your chemotherapy drugs.

Cigna denies teenager’s transplant

Some of you know that I left my job at Cigna after being in the middle of a prior authorization battle involving a teenager in Los Angeles named Nataline Sarkisyan who needed a liver transplant. Cigna denied it. After an appeal failed, the family decided to be a very loud squeaky wheel. Media inquiries started pouring in, and the resulting negative publicity was beginning to tarnish the company’s reputation. The company’s top brass ultimately decided to reverse the denial.

I wish I could tell you this story had a happy ending. Unfortunately, in the days that had passed since the original request for coverage was made, Nataline got sicker. She died, at the age of 17, just hours after the transplant was approved.

For me, it was the final straw. I did not have it in me to handle another horror story. I left the company soon after that. 

Among the things I advocate for now is a top-to-bottom overhaul of the entire prior authorization “industry.” And, as you will read tomorrow, from a former insider who led a prior authorization team, prior authorization shops not only deny coverage for needed care, they have become profit centers within Big Insurance. 

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P.S.: Even when you and your doctor are successful in getting a denial overturned, you’ll probably still get a bill if, like most Americans, you’re in a high-deductible health plan. You could be on the hook for thousands of dollars your insurer won’t cover. Just as when your insurer denies coverage for a treatment, test, or medication you need, you might need to be a squeaky wheel once again to avoid paying more than necessary. As fellow Substacker Marshall Allen advises, NEVER PAY THE FIRST BILL. That’s the title of his essential book, which I highly recommend. A former ProPublica reporter, Marshall explains in his most recent newsletter post how to enlist the media in your fight with Big Insurance or a health care provider.