Last Updated: May 9, 2018
What started as a toothache turned into two years of pain for Scranton resident Pam Moyer. She endured multiple surgeries from infections in her sinus area and Lymph damage to her face.
Moyer’s insurance company eventually paid for these treatments, but only after she persisted through a maze of insurance prior authorizations that she said unnecessarily delayed her care.
It is common for patients to need prior authorization from their health insurance plan before physicians can begin treatment. While insurers say they use prior auth to prevent physicians from ordering too many tests, evidence is emerging about a system that’s inefficient and lacking transparency.
Examples of Inefficiency
Moyer’s case shows just how inefficient the process has become now that many insurers pay third-party companies to review and either approve or deny care.
The third-party company EviCore reviewed Moyer’s prior auth requests for Cigna. EviCore initially denied her six times for tests such as CT scans, MRIs, and bone scans.
Not knowing what to do, Moyer contacted Cigna and was eventually connected to a patient advocate employed by Cigna. The Cigna advocate helped Moyer gain approval on each occasion.
Another third-party, American Specialty Health, denied Moyer’s prior auth for physical therapy after she had already started it. It took a month of contacting the patient advocacy department at Cigna before that prior auth denial was overturned.
“The insurance company does not seem to have control over the abyss of third-party systems,” Moyer said.
Moyer said all her medical issues were treated separately, even though a full medical history might have provided more evidence that the treatment was necessary.
“My medical situation should have followed me in order for the claims to have been reviewed in full context of my medical history. It should not have been isolated,” Moyer said.
Another example of inefficiency, Moyer said, was that EviCore asked her doctor’s office to fax documents to them. Moyer’s doctor’s office faxed the requested documents, but none ever made it to the reviewer at EviCore, according to Moyer.