As patients ‘get sicker while they wait,’ doctors fight insurance delays

MARYSVILLE — When doctors diagnosed Robin Sparks with cancer two years ago, they needed to act fast.

The hard lump on her neck was Stage 3 non-Hodgkin lymphoma, a blood cancer that penetrates bone marrow and attacks the immune system.

Sparks, of Marysville, spent weeks wading through tests and appointments to get her diagnosis. Three months into her six-month chemotherapy treatment, Sparks’ doctors wanted to check her progress. But her insurance company, Ambetter, repeatedly denied a CT scan request.

“The reason was that it was ‘just not necessary,’” said Sparks, 61. “Well, I think it was pretty darn necessary to know if my targeted treatment was working or not.”

On Tuesday, several Washington doctors and patients, including Sparks, joined U.S. Rep. Suzan DelBene in Redmond to discuss how insurance delays harm patients and lead to physician burnout.

Patients “can get sicker while they wait days, weeks or even months in many cases for approval of routine treatments,” DelBene, D-Medina, said Tuesday. “We’ve also seen patients just abandon care because they aren’t sure if they’re ever going to hear if it’s covered.”

Health insurance companies sometimes require patients to prove they need medication or treatment before approving coverage, a practice called prior authorization. The practice is time-consuming for health care workers and delays necessary care for patients, said Dr. Brandon Tudor, an emergency physician at Overlake Medical Center in Bellevue.

When Rick Timmins, of Whidbey Island, had an old knee injury flare up, he found a surgeon within his Medicare Advantage Plan and scheduled an operation. But after Timmins made the appointment, Kaiser Permanente changed his plan’s reach, making his surgeon out-of-network. Not only that, but the company also deemed the surgery unnecessary and declined coverage.

Nearly one in four American doctors reported prior authorization requests are often or always denied, and the delays can have serious consequences for patient health, according to a survey the American Medical Association published last year.

Timmins toughed it out for several months, he said, until he could find another doctor and change insurance plans. Another time, it took his insurance five months to approve a dermatologist visit for a tumor on his ear. In that time, the tumor, which turned out to be Stage 4 melanoma, tripled in size.

When a doctor submits a patient’s treatment plan for coverage, the insurance company uses its own criteria — and its own hired doctors — to determine the patient’s need. Denials are frequent, often leading to arguments between doctors on each side, Tudor said.

“In most cases, the treatment ends up being approved,” said Dr. Elizabeth Wako, an anesthesiologist and CEO of Providence Swedish in Seattle. “So what are we doing all this for?”

Negotiating with insurance companies to treat patients is exhausting, Wako said. And insurance companies may require information through fax or mail, further delaying the process.

Doctors are leaving the profession in droves because of burnout, said Dr. Mark Freeborn, an orthopedic surgeon at Evergreen Kirkland, and insurance delays are a big reason.

“We’re forced to delay care,” he said. “It pushes us out of what we love to do, because we’re not able to do with what we came into the profession to do.”

If things don’t change, the United States could be short 100,000 doctors in a decade, Wako said.

As Sparks can attest, patients could be denied, appeal the decision, and be denied multiple times before finally being approved. And care providers often have to call or fax insurance companies “over and over” again for approval, DelBene said.

“It’s clear that this practice has become outdated, and it’s been abused,” DelBene said.

In January, the federal Centers for Medicare & Medicaid Services announced new regulations to curb prior authorization delays: limiting insurance companies’ prior authorization requests, requiring specific reasons for denials and requiring electronic records of the process. Last month, DelBene reintroduced a bipartisan bill in Congress to codify the new policies.

“When you put sunlight on something, you often see where changes need to be made,” said Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services.

The organization predicts its regulations will save health care providers more than $15 billion over 10 years due to health care staff spending less time on prior authorization and more time “giving people the care that they need,” Brooks-LaSure said.

After three denials, Sparks got her CT scan. Her treatment was successful, but she fears for others who may not be so lucky. In 2022, Sparks founded The C-Suite Center for Hope in Marysville to support local cancer patients and their caregivers.

She spends a lot of time helping Medicare patients understand their insurance coverage and navigating denials, she said.

Insurance “delays could have changed my outcome,” she said. “I hope no one in this country has to have the uncertainty that I did.”

Sydney Jackson: 425-339-3430; sydney.jackson@heraldnet.com; Twitter: @_sydneyajackson.