Last Updated: Sep 15, 2017
Insurance companies say they use prior authorization to prevent physicians from prescribing too much medication or ordering too many tests. But physicians say the use of prior auth has grown out of control – and few stories illustrate it better than that of Joe Stanziano.
Stanziano, who currently resides in Montgomery County (Pa.), used to own a bakery in New Jersey. Ten years of carrying heavy bags of flour and working 18-hour days took a toll on his back.
Stanziano had just undergone his fourth back surgery in five years and was taking pain medication to help with his recovery. Things were progressing well enough for Stanziano to begin taking a smaller dose of the medication – a process known as tapering that could eventually allow him to wean off the medication altogether.
The problem is, Stanziano's insurance company denied payment of the lower dosage that his neurologist prescribed. Hours turned into days and Stanziano continued to wait for his insurance company's approval.
When the medicine ran out, the withdrawal symptoms began.
"Cold sweats. Shaking. You don't have control," Stanziano said.
This wasn't a one-time mistake by his insurance company.
Stanziano's neurologist prescribed a lower dose of pain medication five times. It was denied five times for up to a week before it was approved.
As the delays grew longer and withdrawals continued, Stanziano opted to buy the medication out of his own pocket. Each pill cost $60.
"One could imagine a reason for (denying it) if we're increasing the medication, but in Joe's case, we were gradually decreasing the medication," said Daniel Skubick, MD, Stanziano's neurologist. "In spite of the fact that we were doing the right thing (by lowering his dosage) – getting him off opioids – pre-certs would still be coming."
Stanziano said he was never given a clear answer as to why his medication decrease required a prior authorization.
"You could talk to two different people (at the insurance company) in the same day and get two different answers," he said. "Explain to me the logic – why are you denying it when we were trying to reduce (the medication)? Does it make sense to you?
"Are you trying to cut costs, or are you trying to cut lives? I can understand trying to cut costs, but put them in my situation. Let them be on the medication for a certain period of time, and not be able to refill it, and have to go through what I went through."
The Pennsylvania Medical Society is advocating for decreasing patient wait times from prior auth and increasing transparency from insurance companies.
Has Your Care Been Delayed By Prior Auth?
Has your care been delayed by a prior auth denial? If so, we encourage you the make an official complaint to the Pennsylvania Department of Insurance. Use to this link and follow the instructions.
Your official complaint to the Pennsylvania Department of Insurance will help support prior authorization reform in Pennsylvania.