Prior Auth Delay Allowed Pittsburgh Woman’s Undiagnosed MS to Progress

Last Updated: Sep 15, 2017

Kristen O'Toole lived a healthy, active life as communications consultant in Pittsburgh. That changed suddenly and dramatically in 2014 when she began experiencing back pain.

As the pain intensified, O'Toole realized that something was seriously wrong.

Her physician wanted to do an MRI to figure out the problem – which he suspected was a herniated disk – but told O'Toole that she would need to complete several sessions of physical therapy and get an x-ray before the insurance company would authorize the MRI.

O'Toole went through this protocol without experiencing any improvement for several weeks as her condition worsened.

By the time O'Toole's insurance company approved the MRI, she could barely walk. The MRI showed a severely herniated disk that led to an emergency surgery. But that only hid the real issue.

A few days after surgery, O'Toole woke up in the rehab wing of the hospital unable to see or speak. That is when physicians discovered that she had multiple sclerosis.

"I didn't know the severity of what I had," she said. "The only way they had of knowing that would be to do the MRI. If I had gotten the MRI earlier and started on the MS infusions, I really believe it could have kept some of these symptoms at bay. Maybe I would have never ended up in a wheelchair."

Insurance companies use prior authorization as a cost-cutting measure to prevent physicians from ordering too many tests. But 86 percent of physicians nationwide say they've seen an increase in the number of prior auths they are required to do, and it has had a harmful effect on patients.

The Pennsylvania Medical Society and a coalition of 50+ physician and patient advocacy groups support legislation that would reduce patient wait times by streamlining the system and forcing insurance companies to be more transparent.

O'Toole said she still feels the impact of prior auth delays because the medication she uses to treat her MS often changes. Delays in getting approval for new medication not only impact her health, but her wallet as well.

"I have new symptoms that I have to treat," she said. "And every time I go to a new pill, that requires prior authorization. That required me sometimes to pay full price for the drug, because it wasn't authorized yet. It's very expensive."

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. 

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