Health insurance authorizations & their real consequences

A Melbourne man who spent three decades fighting crime is now fighting his insurance company. He contacted Action 9 after getting denials for medical testing that his doctor ordered, and he believes could save his life.

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“I’ve been through a lot in my career. So, now that I’m retired, I kind of want to want to last to see my grandchildren grow up a little bit,” said Cyril Hopping as he described his dilemma to Action 9 consumer investigator Jeff Deal.

Hopping proudly served as a police officer with the City of Melbourne for 31 years. At the age of 55, he now has health concerns that keep him up at night.

He said, “I have a horrible family history. My dad died of a heart attack at 57. My brother got diagnosed with the ‘windowmaker.’ So, he ended up having a triple bypass at 55.”

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Thankfully, his brother survived the surgery. But that scare, his father’s sudden death and now his own current health issues prompted doctors to order multiple tests.

He showed the Action 9 team photos of his father as he thought back on his life. “That’s my dad right here,” he said pointing to a picture of his dad behind the wheel of a classic racecar that he used to drive.

Despite his concerns and his doctors’ requests, in a span of six months, he’s received at least four denials from his insurance carrier Aetna. The denials include nearly a thousand dollars’ worth of blood work and a cardiac stress test.

“I’m just frustrated. I don’t know what to do. Like I said, I don’t want to end up, you know with my heart, I don’t want to end up like my dad,” Hopping said.

Dr. Bruce Scott, President of the American Medical Association believes these types of denials are a big problem.

“This is a serious situation that needs to be addressed and it needs to be addressed now,” Dr. Scott said.

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He called the authorization process archaic and said, way too often it leads to unnecessary delays and treatments for patients. He said it not only affects their care, but also their wallets.

Dr. Scott told Action 9, “The reality is, is that it’s actually costing more money. When you look at it globally because of the unnecessary medications, the unnecessary steps that are taken, the hospitalization or the visits to the urgent care center or the emergency room, when the therapies don’t work. What we need to do is restore the trust in the physician and the medication, the surgery, the diagnostic test that the physician has ordered is what the patient deserves.”

The AMA recently surveyed a thousand physicians. 94-percent claimed prior authorizations delayed necessary care. 93-percent said it negatively impacted patients and nearly a quarter said these authorizations caused serious medical problems.

“Physicians are fed up with it. Physicians just want to take care of patients. That’s why we all became physicians in the first place. And this burden that is placed upon us, it’s gotten worse every year,” said Dr. Scott.

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Action 9 contacted Aetna about Cyril Hopping’s frustrations. A spokesman told us they’re now helping him appeal those denials. He said they’re always focused on helping members access quality, affordable healthcare and prior authorization helps ensure members receive appropriate care when they need it.

For Cyril Hopping, though, these denials after paying costly monthly premiums feel like a gut punch and he believes in the end they’re putting money over his health.

“I guess it’s cheaper for Aetna if I go ahead and die and then they won’t have to pay anything,” he said.

Dr. Scott told Action 9, current bipartisan legislation on prior authorizations that has been introduced to congress would be a big step in the right direction.

For information on that legislation and the efforts by the American Medical Association to make change, click here.

For helpful strategies on navigating health insurance denials, the Patient Advocate Foundation has them laid out here.

The Patient Advocate Foundation can also help you though the process if you need assistance. Click here if so.

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