Sally Nix was furious when her health insurance company refused to pay for the intravenous fluids she needed to relieve her chronic pain and fatigue.
Nix has been suffering from a combination of autoimmune diseases since 2011. Brain and spine surgery did not relieve the symptoms.She said nothing worked for her until she started IV immune globulin The end of last year. Commonly called IVIG, the treatment uses healthy antibodies from other people’s plasma to boost her weakened immune system.
“IVIG turned out to be my big hope,” she said.
That’s why, when Knicks’ health insurance company began refusing to pay for her treatment, she took to Facebook and Instagram to vent her anger.
“I was talking to Kane about it,” said Nix, 53, of Statesville, North Carolina. He was forced to pause treatment, she said, because she couldn’t afford to pay more than $13,000 out of pocket every four weeks. “Sometimes you just have to denounce cheating,” she wrote on Instagram. “This is one of those times.”
Pre-approval is a common cost-saving tool used by health insurance companies, requiring patient and physician approval before proceeding with many tests, procedures and prescriptions. Insurers say the process prevents medically unnecessary treatments and helps control costs. But patients argue that often time-consuming and frustrating regulations create hurdles that delay or deny them access to needed treatment. In some cases, delay and denial equate to death. the doctor says.
That’s why desperate patients like Nix, and even some doctors, are openly threatening insurance companies on social media to get their tests, drugs and treatments approved. is.
“Unfortunately, this has become a routine practice for us to resort to when no progress is being made,” said Shezad Saeed, a pediatric gastroenterologist at Children’s Hospital in Dayton, Ohio. In March he Tweeted a photo of an oozing skin rashaccused Anthem of denying the biologic treatment the patient needed to alleviate the symptoms of Crohn’s disease.
In July, Idaho-based psychiatrist Eunice Stallman first joined X, formerly known as Twitter. Share what your 9-month-old daughter looks likeZoe had been denied pre-approval for a $225 drug she had to take twice a day to shrink a large brain tumor. “It shouldn’t be this way,” Stallman said.
The federal government is proposing ways to reform preapprovals that would require insurers to be more transparent about denials and reduce response times. These federal changes, if finalized, will go into effect in 2026. But even then, the rule applies only to some categories of health plans, including Medicare, Medicare Advantage, and Medicaid plans, not employer-initiated health plans.Roughly speaking, that means half of the Americans No benefit is gained from the change.
The Patient Protection and Medical Expenses Act of 2010 prohibits health insurance plans from denying or revoking coverage to patients based on pre-existing medical conditions. AHIP, a trade group formerly known as America’s Health Insurance Plans, did not respond to a request for comment.
However, some patient advocates and health policy experts have used preapproval as a “potential loophole” in the ban as a way for insurers to deny treatment to the most expensive patients. Kay Pesteina, a KFF vice-president and health policy expert, explained that Co-Director of the Program on Patient and Consumer Protection.
“They get premiums, they don’t pay out the premiums. That’s how they make money,” said a health care consultant and former Kentucky internal medicine doctor who was employed as a medical reviewer by Humana in the 1980s. Physician Linda Pino said. later became a whistleblower. “They just drag you on and on until you die, and you’re totally helpless as a patient.”
However, there is reason to hope that the situation may improve slightly. Some large insurance companies Voluntarily revise previous authorization rules To relieve pre-approval obligations for physicians and patients.and many states pass laws Suppress the use of prior authorization.
“Nobody’s saying it should go away completely,” said Todd Askew, senior vice president of advocacy for the American Medical Association, ahead of the group’s work. annual meeting in June. “But it needs to be right-sized, it needs to be simplified, and it needs to create less friction between patients and their access to benefits.”
Customers are increasingly turning to social media to raise complaints across all industries, and companies are taking notice. According to his 2023 “National Consumer Anger Survey,” conducted by Customer Care Measurement & Consulting in partnership with Arizona State University, nearly two-thirds of his complainants had some reaction to an online post. I am reporting that I have received
some studies suggest Businesses would rather engage with disgruntled customers offline than respond to public social media posts. However, while many patients and physicians believe that online degassing is an effective strategy, it remains unclear how often this strategy works in overturning previous approval denials. be.
“It’s no joke. The fact that we’re going to get these drugs that way is absolutely sad,” said Brad Constant, an inflammatory bowel disease specialist who published the preapproval study. said. found his work Advance clearance has been shown to be associated with increased likelihood of hospitalization in children with inflammatory bowel disease.
Said said the case was subject to a peer-to-peer review the day after he posted the photo of the skin rash. This means that pre-approval denials will be scrutinized by insurance company representatives with medical backgrounds. In the end, the biologic that Said’s patient needed was approved.
Stallman, who is insured through her employer, said she and her husband were willing to pay out of their own pocket if Blue Cross, Idaho, did not rescind Zoe’s drug refusal.
Insurer spokesman Brett Lambeck said Zoe’s medication was approved on July 14 after the company consulted outside experts and obtained more information from Zoe’s doctor. .
Stallman posted details of the ordeal online only after his insurance company approved the drug, in part because the insurance company said it was due to the 90-day policy review in October. She said it was to prevent her from refusing treatment again. “The power of social media has been tremendous,” she says.
Nix had insurance for nearly 20 years with Blue Cross Blue Shield, Illinois, through her husband’s employer. Company spokesman Dave van de Wall declined to comment specifically on the Knicks. However, the company said in a prepared statement that it provides administrative services to many large employers who design and fund their own health insurance plans.
Nix said she was contacted by an insurance company “escalation expert” after she posted her complaint on social media, but that didn’t help.
And in July, after KFF Health News contacted Blue Cross Blue Shield, Illinois, Nix logged into her insurance company’s online portal and found $36,000 of her outstanding claims marked as paid. I discovered that there is No one from the company contacted her to explain her reasons or what had changed. She also said she was told by the hospital that she would no longer need to get prior approval from her insurance company before her IV drips resumed in late July.
“I am very excited,” she said. But “this should never have happened.”
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