Prior Authorization: Lessons, Strategies and Stories

Hey there—

Time to follow up on a podcast episode from earlier this year, where New York Times reporter Ron Lieber talked about his family’s horrifically-tense experience with prior authorization, the lessons he learned, and a tool he made for providers to help their patients.

One thing we didn’t unpack here from that conversation: Some of Ron’s practical takeaways for those of us who aren’t medical professionals.

Then, a few weeks after our episode with Ron, our pals at KFF Health News published a story about avoiding prior-authorization hassles involving prescription meds.

And then: Some of you have shared a couple of tales from the wider Internet that I wanna pass along. One is what I’d call a grimly-comic horror story. It could make you laugh, cry, or maybe lose your lunch. Or all three.

The other is an ongoing epic, with a hero you’ll root for, and learn from.

I’ll start with the lessons — they’re quick — and you can decide if you want to stick around for the, um, show.

The lessons boil down to: Get ahead of things. And sign up for some potentially-annoying (but important) texts and emails.

Got a procedure? Start asking questions

Ron’s story involved a surgery his family had been planning for months — until the insurance company swooped in at the last minute with a denial, giving Ron’s family less than 48-hours notice. On a weekend.

When Ron first wrote about the experience in the Times, he concluded with some advice he wished somebody could have given him. The minute your provider says you need a procedure, start asking questions:

• Could prior authorization come into play here?
• How soon can your office or institution put in a request to the insurance company for that authorization, to avoid any last-minute whoopsie?
• What’s the department (or the person) in your office or institution that’ll handle this request? What’s their phone number?

For folks who have been through the wringer lots of times, this may seem too obvious to qualify as advice… but for lots of others, like Ron’s family, prior authorization is new territory.

Even for folks who have some familiarity — say, like me — having a checklist of questions to ask is a handy thing, especially when you’re in a potentially tense, novel situation, like being told that you need surgery.

The whole idea is: If you end up having to fight with your insurance, you want as much time as you can get, to work things out.

Taking meds? Check this expiration date

The KFF Health News story starts with Jaclyn Mayo’s rude awakening. She went for a refill on a drug she’d been taking — and that her insurance had been covering for seven months — only for her pharmacy to refuse to fill prescription number eight.

It took her a bunch of phone calls to figure out that the prior authorization on her prescription had… expired. For some reason.

Her provider filed a request to renew the authorization, but the insurance company wanted seven to ten business days to process the request.

She spent two weeks without meds that had been helping mitigate symptoms of multiple sclerosis: like sleeplessness and numbness in her hands.

So, as the KFF story advises, if your insurance company makes you go through prior-auth on a drug once, they’ll probably do it again. So call and ask: When does this authorization expire?

Then, set a date — maybe a month ahead of that expiration — to get the next request in motion.

And set aside time in the following weeks to follow up if you need to. Press them for a decision, maybe file an appeal, maybe scratch around for alternatives.

Having gotten a drug approved the first time, you’re probably familiar with the drill, but just in case: Check out our Prescription Drug Playbook to get an idea of what might be involved.

Sign up for annoying emails and texts

This was another thing Ron Lieber wished someone had told him earlier. They got word of the insurance company’s decision by U.S. mail.

He asked them later: Why hadn’t the company gotten in touch in a more-immediate medium, like a text or an email?

They told Ron his family hadn’t “opted in” to paperless communications.

So, Ron’s advice: Log on to your insurer’s website, figure out how to opt in, and then watch your inbox carefully.

Ron told me he keeps a special, private email address just for personal correspondence — and spends time unsubscribing it from spam every week. Which I should do too, but ugh. And so should you.

OK, ready to laugh, cry, and maybe lose your lunch?

If not, SKIP the next video, which a listener named Jaimy Honig sent with this message, after hearing the Ron Lieber episode:

Great episode. I am a doctor. My daughter had a denial and since she is an actress, writer, comedian, and filmmaker she did a YouTube video about it.

Content warning: ACTUAL ON-SCREEN VOMITING. A lot of it. (But the video is funny, if you’ve got the stomach for it.)

Maybe set aside time for this epic

In January, a listener in Colorado sent a tip:

I love what this guy is doing to bring awareness to the issues so many people are having with insurance companies. Through his own story, he shows you what it’s like to get a devastating diagnosis treated/covered.

They linked to an Instagram video from a man named Keaton Herzer: Cigna is denying my liver transplant surgery (it could save my life).

… which turns out to be part of a long series, where Keaton shows us his fight — including a set of eight videos where he’s actually on the phone with the insurers, most of which were shot while he was in a hospital bed.

The good news: He won. He’s scheduled for surgery soon. And he recently posted a series Untangling the Insurance Web of Chaos — complete with whiteboard — showing the intricate, confusing chain of corporate middle-companies that made his fight so difficult.

I got to talk with Keaton in January. He’s a remarkable guy, and I hope you’ll hear him on the podcast later this year.

Meanwhile, if you’ve got the time for it, you’ll learn a lot by checking out his Instagram. He’s on TikTok, too.

That’s it for this week— catch you soon. Till then, take care of yourself.

— Dan