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Gilbert Aguirre is a firefighter in Arizona. He was diagnosed with chronic myeloid leukemia seven years ago which his doctors said he developed on the job. Even though Aguirre could retire now, he has to keep working to cover his medication to keep the leukemia at bay which is $15,000 a month. That will continue, in his words, “until [his] body can’t hold up anymore.”

Throughout the duration of his diagnosis, his health insurance company, Copper Point—insurance which he gets through the city of Goodyear, Arizona—has repeatedly rejected his doctor’s request for treatment. The most recent denial was earlier this year.

It can get worse.

In early 2020, doctors for a Michigan cancer patient, Forrest VanPatten, said he needed Car-T treatment to kill the cancerous cells in his bloodstream and save his life. But VanPatten’s health insurance company, Priority Health, denied it and said it “wasn’t a covered benefit.”

So, the VanPattens did what hundreds of thousands of Americans have to do every year: start a GoFundMe to try to pay for medical bills. His son took to Twitter to talk about what his family was dealing with.

Donovan @TheeDVP

My father is in need of a Car T cell transplant in order to save his life; however, he is being denied by our insurance company. I am asking for any help to spread the word to get him the treatment he needs. @FOX17 @wzzm13 @WOODTV PLEASE READ & SHARE #CancerSucks

The insurance company, despite not being tagged directly in the tweet, saw it and replied.

Priority Health @PriorityHealth

@TheeDVP @FOX17 @wzzm13 @WOODTV Hi Donovan, your Dad’s care is very important to us and we appreciate your concern. In the interest of protecting the privacy of our member, it’s our policy to keep conversations and concerns about coverage and care confidential. Please know that we are working on the situation.

The VanPattens also reached out to their local news to try to get help and a story ran on February 13, 2020.

Forrest VanPatten died four days later.

These are just two absolutely horrifying examples. The problem in both these cases—and in millions more American lives—is prior authorizations. As I mentioned in an earlier post, it’s when your doctor recommends a procedure or treatment and instead of, you know, getting that procedure or treatment next you have to get approval from someone who isn’t a doctor at your health insurance company.

I’m sure you can see the obvious conflict of interest—insurance companies have a financial incentive to deny those requests. The fewer requests they approve, the less they have to pay out and the more money they make.

As I know so many of you understand, if your health insurance doesn’t cover your treatment, you’re left with few options. If you aren’t wealthy, you could try joining the hundreds of thousands of people and families crowdfunding online to try to pay for medical bills may be the only chance to get treatment without spiraling into debt.

The American Medical Association describes prior authorizations as “time-consuming barriers to the delivery of necessary treatment” in a new report. The physicians group pushed for reforms to prior authorizations in 2018. Despite this broad call for changes to how the industry handles prior authorizations, very few physicians report any substantive changes. And, for many patients, essential care is often delayed or inhibited.

A recent survey of physicians conducted by the AMA found that 93% of doctors report delays in care due to prior authorizations. 82% of doctors say patients at least sometimes abandon treatment entirely because of prior authorizations.

Source: American Medical Association

To make matters worse, 34% of doctors have reported seeing “a serious adverse event for a patient in their care” due to prior authorizations, with 24% indicating a patient had been hospitalized as a result. 8% say prior authorizations have “led to a patient’s disability/ permanent bodily damage, congenital anomaly/birth defect or death.” This is abhorrent but entirely unsurprising. It reflects the terminal rot in America’s healthcare system.

I wanted to get a better understanding of what the process was like. Who is doing the denials? It certainly isn’t the executives. So, I found someone who used to review claims for a healthcare giant. And like so many of us, he ended up in a job he resented because he desperately needed healthcare.

Shaun, 41, wanted to work on planes for his career. He majored in aviation maintenance and eventually enlisted in the Air Force.

“I was trained in finding cracks and structural issues in aircraft and related parts. The tech term is non-destructive inspection,” he told me. “I was in school for it all in 1999-2001. The aviation field was booming. I was already committed to the Air Force when 9/11 happened. When I returned from military service the aviation market was blown to bits.”

He tried to find new work using some of the skills he picked up in aviation. Bridge and tower inspections was similar enough and paid well, so he did that. It was rigorous work. He would be gone for weeks at a time only to have a few days at home before immediately hitting the road again for another stint. He went all over the country but it left him feeling drained.

“Eventually all the manual labor caught up to my bad genetics and my back blew out for the first time. I paid out of pocket for that surgery. I was 30,” he said. When he was able to work again, he spent some time as a UPS delivery driver before injuring his back again.

Unable to do physical labor and in desperate need of a job with insurance, he eventually found an opening at a healthcare company that was a licensee of one of the country’s insurance giants. It paid $16 an hour—while nowhere near a living wage, it was around double what other jobs in his area paid—and offered health insurance after 90 days.

“I started out with easy things like getting regular visits to process correctly and eventually got moved to records and authorizations. I did not enjoy any of it really. I am a goal motivated person so hitting high efficiency numbers etc., always felt good when I was getting things approved. So there was a tiny bit of ‘I am helping’ to it on some occasions,” Shaun said. “After being moved to medical records and authorizations I absolutely hated my job and everyone involved in it. He became a claims adjuster.

What he saw horrified him. There was the “Not Covered Sick Baby” policy, for instance.

“[That meant] if the plan does not want to cover babies born with serious issues, they just won't. If they do cover a ‘sick baby’ you have to jump through hoops like mad to get them covered. Like electing to add the baby to the policy with very specific parameters having to do with time, or the age of your policy could make them not covered,” he said. “So if you have a sick child at birth you have to jump through all kinds of hoops while dealing with a sick child.”

It should be noted that the United States has one of the highest infant mortality rates among OECD countries.

Shaun was also mortified with how he had to handle cancer treatment claims.

“If you have cancer, and the Doctor gives you treatment B [but] doesn't give you treatment A first, you will be paying for all of it out of pocket unless you get a prior authorization. Those are almost always denied,” he told me. “90% of those denials that are handed down are handed down by people that have as much medical training as I do, which is absolute ZERO.”

It didn’t make any sense to him. He ultimately knew why his company was having him do this—profit—but couldn’t rationalize why a physician who is directly treating a patient is being told their recommendation for care was being met with resistance and obfuscation.

“My dumb ass had a list of reasons to deny the doctor an authorization. The doctor had a very limited amount of things they could say or submit to get that authorization but I was not allowed to tell them what those things were,” Shaun said.

There were other circumstances, too, that were much more common and generated denials that resulted in essential care not being covered.

“I [had to] deny things for lack of medical records. Mind you we could not guide them in what we wanted, but we would request records and if the records did not contain what we wanted. We would deny the claim. Then they would submit more records, we would deny again and tell them too bad, you aren’t getting it covered no matter what you send us now, you have reached your limit for resubmissions/appeals,” he said.

He grew resentful. The money was sorely needed, even if it wasn’t great, and he especially needed the health insurance. After some time, his health issues caught up with him again. When it was his turn, Shaun found himself dealing with the same burdensome approval process he had to enforce.

He needed an MRI and surgery on his back. His own company—and the insurance they administer—denied him his claim. He hadn’t completed physical therapy yet. So, he went. But the therapy rendered his right leg and lower back paralyzed.

“I ended up in the hospital in the most pain I have ever been in. I felt like someone was gutting my leg like a fish while removing my right kidney. I could not move,” he said. “The EMTs had to give me so much morphine and fentanyl that I passed out and almost overdosed naked in my basement.”

His insurance denied his emergency claim at the hospital. Then they denied the MRI and surgery he still desperately needed because he hadn’t completed the physical therapy that just hospitalized him.

“As a result I have permanent nerve damage in my right leg and back. I can not feel my right foot, half my calf, and most of my hamstring area,” he told me. “I had to switch health plans to an HMO, wait two years to go to the doctor for anything back related at all just to get where I am now. Had I gone to the doctor for the back pain they could have fought it as an ongoing issue.”

The company would try to keep other claims adjusters in good spirits because ultimately they knew the people they were using to do their dirty work understood what was happening. The office would hold motivational meetings where management would get into costume and use gimmicky language in a feeble attempt to create a sense of camaraderie among staff, but really just designed to placate employees a bit longer. Outside of work, staff would commiserate at happy hours because they felt nobody else would understand the complexities of the work.

“It is a very sad existence if you don't meet other people in the office to get along with and vent to because no one outside of that job has any idea what you do no matter how long you explain it,” he said.

Finally he had enough. He couldn’t handle the weight on his conscience any longer. So he acted on it. Shaun knew it was a terrible system that deprived honest people of essential care, so he wanted to wreak havoc from the inside.

“I did feel guilty when I had to help deny some of those claims, especially knowing literally how some of them felt. I did the bare minimum, put my head down, did my work and moved along,” he said. “I finally got to where I was not audited as much as when I started and that’s when I started just saying fuck it and allowing claims. That caught up to me finally. I laughed the whole way out of the office when I got fired.”

Clerical errors and missing submission deadlines were common but could lead to claims being rejected. That didn’t sit well with him.

“The ones I approved when I shouldn't have were based in shit policy, like missing physical therapy, MRI with contrast instead of without, something done out of order,” he said. “But if a clerical error caused the denial and it would have been otherwise approved I would just fix the clerical error even if I wasn’t supposed to.”

“If the claim was not submitted in a certain time frame it could be rejected even if deemed medically necessary. I did not agree with that either. Those were the 10-20% I approved anyway and got fired for,” he said.

In the end, he ended up approving nearly four times as many claims that required prior authorizations than his coworkers.

A recent report found that hospital claim denials in 2020 had risen by 23% over the prior four years.

Thank you for reading. If you enjoyed this piece, please share it and leave a comment. And if you’d like to subscribe to this Substack, can do so below. A portion of proceeds from monthly subscriptions goes to groups supporting our unhoused friends and neighbors.

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Cover photo courtesy of Marco Verch/Creative Commons

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