Dozens of physicians have already shared their stories with ISMA, including:

Lois K. Lambrecht, MD: “OptumRx prescription for Percocet. (My patient) has been on it for the past 15 years: same diagnoses, same insurance. I don't have electronic medical records and can't upload documentation, thus it was being denied. I asked for an expedited case, but it was denied as I didn't have the required documentation, such as a signed agreement, etc. However, no documentation specifics were included in the PA. I called and spent 15 minutes on the phone. Then, a pharmacist who left no name or return phone number requested the documentation I needed to provide, but there was no way to get it to them. Twenty additional minutes were spent waiting to speak with a "peer" who asked if I would attest to the documents needed. They then told us they would let us know if it was approved. My patient was without their medication for five days. Two years ago, I spent 85 minutes on this patient's PA. PAs adversely affect everyone.”

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Kyle Littell, MD: “I have been discharging patients from the hospital with a new diagnosis of COPD or uncontrolled COPD who need new inhalers at home. There are many types of inhalers, so we attempt to prescribe the ones that are being used in the hospital. They will typically require a PA due to the high cost of these medications. Several times, we have gone through the process of a PA only to have the insurance deny the medication and send a list of approved similar inhalers on the ‘formulary’ with the insurance. However, once submitted, the medications they recommended still require a PA to be completed, and on occasion the medication that is on the ‘approved’ list apparently is not ‘approved’ any more as the formulary changed sometime between when the fax was sent and when the PA was done. We then have to submit a third medication, also requiring a PA. We have been working diligently to try to identify these medications earlier than the patient's discharge date. For this process, we learned it could take several days, but if missed, it can delay the patient's discharge if they absolutely require these medications to prevent rehospitalization. Also, sometimes the insurance will send a note with the PA to look up the approved list of medications based on the patient's insurance plan. The generic website they send is not user-friendly and has so many insurance types that you aren't sure what you are even looking at.”

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Andrew Skinner, MD: “I am the medical director at an inpatient facility that provides acute detox for substance use disorders. A teenage patient came in reporting daily use of 60 mg of illicitly obtained methadone and injecting fentanyl along with that on a daily basis. Also regular IV methamphetamine use. The patient had a previous history of failure with outpatient treatment with buprenorphine via Sublocade. The patient was admitted for opioid detox. The patient’s entire stay was denied by Anthem HIP, saying they did not meet the criteria for inpatient detox. We are in the midst of the fentanyl epidemic. Anybody with basic familiarity with substance use disorders understands that if we turned this patient away, they are almost certain to continue using. This is literally THE MOST LETHAL CONDITION for patients in this age group! It is their leading cause of death. Adding in daily doses of methadone only serves to greatly increase the risk of fatal overdose."

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John Fye, MD: “Prior authorization was required to perform a screening colonoscopy at a local hospital. The insurance carrier preferred an outpatient surgical clinic. Insurance was informed there were no such facilities within a reasonable distance. A request to do the procedure at the hospital was approved. Later that week, prior authorization was required to do a screening colonoscopy at the local hospital. This happens weekly. If an outpatient surgical clinic doesn’t exist today, it is unlikely to exist in 72 hours. Must this waste of nursing staff time happen over and over?”

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Adam Amos, MD: “I tried to prescribe Trelegy to (an adult patient) with severe dyspnea and ongoing progressive COPD, and was denied. Then I tried to do Spiriva respimat along with Breo, and these were denied as well. We just received a recommendation to try Spiriva handihaler instead, and it triggered another prior authorization request.  Meanwhile, the patient has been suffering without treatment and off work for four months while waiting for medications to be approved.”

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Sam Horton, MD: “I was asked to do a peer to peer for CPAP supplies on a regular CPAP user. Begrudgingly, I called Caresource (Marketplace Indiana) but couldn't get past the representative while trying to arrange a "peer to peer.” The representative said they couldn't arrange the conversation without an authorization. However I couldn't get across to him that this was the peer-to-peer line (they later confirmed it was). I was calling to GET the authorization. Thirty minutes later, at the end of lunch, I gave up. My patient will now have to wait 180 days (rules the insurance created, because the peer to peer wasn't completed) to get new supplies. And I feel more sorry for the truly sick patients whose telephone calls couldn't be answered, and for the early afternoon patients who didn't get my full attention because I was still fuming over the complete waste of time.”

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Mark H. Stein, MD: “One of the major problems with prior authorization is that the insurance companies do not have people available at all times. For example, if a patient is discharged at night and needs a medication that requires prior authorization, there is no way to help the patient. The patient is harmed by the actions of the insurance company. This is not a proper way to treat our patients.“ 

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Margaret Zelasko, MD: “Working in internal medicine, I work on multiple PAs a week. The average primary care nurse spends about 15 hours a week on PAs. Not only does this slow productivity down for nursing education, support, and working towards patient goals of healthy living, but it puts patients' lives/health status at risk due to waiting for care to get authorizations answered. It is not always cost-effective to deny a patient’s medication due to other costs the patient may accrue with possible hospitalization, readmissions, and surgeries that could have been deflected with medication. It is also gross negligence on behalf of the insurance companies to deem a medication not authorized on a person that the insurance company has never had a face-to-face evaluation with.”

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David Welsh, MD: “A senior patient was hospitalized for GI symptoms: pain, nausea, vomiting, diarrhea and dehydration. They have multiple co-morbidities. The patient was treated supportively with some improvement. After discharge, their stool studies came back positive for a parasite. Appropriate medication was ordered (per CDC website and ID). The initial request was denied. Multiple calls were made. PA was required and initially denied. Peer-to-peer was requested. The patient became more ill, and readmission was considered just to get them the appropriate medication. After nearly a week, the patient was able to get their medication and improve.”

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Peter H. Baenziger, MD: “(An adolescent patient) with terminal brain cancer and associated nausea, anorexia had to wait six days from initial script writing to picking up for a script for relief from their symptoms.”

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Mercy Obeime, MD: “I’m board-certified in hospice and palliative medicine. I’m also certified in addiction medicine. I have a patient who was on buprenorphine for over two years and was doing well in recovery. They hurt their back, and their pain medication needed to be increased. Because of their history and risk of overdose, I transitioned them to my chronic pain clinic and started them on methadone. Their insurance has refused to prior authorize their methadone, which is working well and only a small fraction of the buprenorphine cost. I think this is a waste of resources and unfair treatment of my patient, who has been paying out of pocket for their methadone for months.”

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Carrie Davis, MD: “About one year ago, I had a patient with a condition called lichen sclerosus. The standard of care for this condition is to start with a topical medication called clobetasol ointment. This patient needed that plus something else, as they were not controlled on that alone. I prescribed a second medication called tacrolimus ointment. Both of these were denied. I appealed and got denied again, so I requested a peer-to-peer review. I was told to supply a list of references for the use of these medications for this condition and to submit those before the peer-to-peer review, which I did. I set a time to receive a phone call. That phone call came an hour late when I was home cooking dinner for my children. The peer was a pharmacist. The pharmacist actually told me that they knew that clobetasol is the standard of care for lichen sclerosis and that tacrolimus ointment has been used for it, too, and was already aware of the literature on that. However, they had ‘to deny some medications every now and then or (I) get in trouble.’ I was appalled. The patient had to wait two weeks to receive their medications. I spent my own time doing appeals, literature searches, and doing peer-to-peer for something that should have been approved in the first place. However, in this situation, a game was played. And shockingly, the pharmacist on the peer-to-peer call admitted that to me.”

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Douglas Neeld, MD: “I was attempting to get one of my asthmatic patients a combination inhaler (i.e. Advair). It was denied and came with a letter stating the other three options in the drug class that were covered (Symbicort, Dulera and Breo). Every time I sent another inhaler in, I received a refusal saying the OTHER three inhalers were covered. I did this until I exhausted all four inhalers in the class, leaving me with no option for my patient. This has happened more than once. It was Indiana Medicaid. The denials came with no contact information. I was forced to give my patient systemic steroids (more potential side effects) and inhalers that were not in keeping with current therapeutic guidelines. If I can prevent an ER visit with the proper medications, everyone wins.”

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Sarah Perryman, DO: “Every biologic medication I write for goes to a specialty pharmacy for prior authorization processing, or infusions require specialized staff to complete PA paperwork before an infusion can be given. This can sometimes take several weeks before a patient even receives treatment. Meanwhile, my patients are flaring, experiencing debilitating inflammatory arthritis symptoms. Sometimes symptoms are so severe that they have to be hospitalized, driving up even more of the cost of health care, and not to mention inhibiting these patients' quality of life." 

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Jeffery J. Soldatis, MD: “Pre-op testing request, prior to authorizing surgery, then denying the test AFTER it was completed. We requested authorization for a surgical reduction/fixation of an upper extremity fracture. The insurer requested additional advanced imaging before authorizing surgery for a displaced fracture -- obvious on plain films. Then, two days after the advanced imaging was completed, they DENIED the imaging but authorized the surgery. Additionally, the patient was in limbo until the day before the surgery because that is when we finally received authorization for the surgical procedure.” 

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Richard Feldman, MD: “I had a patient who had a rapidly progressing autoimmune neurologic disease who failed high-dose IV steroids and serum plasmapheresis. After a lot of prior authorization issues, they were finally approved for a specific brand-name IVIG. This specific brand was not available anywhere.  I submitted multiple PAs for a different brand name that was available. I went in circles trying to get this brand approved and never could get approval. The neurologist told me that sometimes you just have to put someone in the hospital to get the patient's needs. The patient was deteriorating.  We put them in the hospital and ordered the IVIG. I do not know which entity actually paid for the IVIG, either the insurance company or the hospital. This was an avoidable, expensive hospitalization.”

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Scott Curnow, MD: “My focus is on lack of fluidity in changing prescriptions during supply change disruption, especially stimulant medication. For example, Focalin XR, Adderall XR, and their generics are in short supply. I prescribed a script for #60 of 5 mg capsules instead of #30 of 10 mg capsules, and that triggered a prior authorization from insurance. Really. If a patient is switched to a different stimulant for a month because they can't obtain their current stimulant, then prior auth is generated. In Indiana, controlled substance scripts cannot be transferred from one CVS to another, so a physician’s office or parent must call around to often five to 10 pharmacies to find their particular med. In 2024 that inefficiency is ridiculous."

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John E. Francis, MD: "A prior authorization and PA number were requested and provided. Then, a day before the operation, the hospital called to say the insurance company said the patient was NOT authorized. My assistant spent over a half hour trying to understand what went wrong, and the insurance rep refused to provide a supervisor to discuss, stating it would take up to five to 10 days to review. So, I got on the call and was able to speak to the supervisor (took a surgeon to get to that level), who explained the initial authorization was provided by 'someone in training' who had mistakenly authorized the operation. They were willing to 'rush' a review over the next 48 hours even though the patient had been initially authorized for the following morning. The patient had already been in the ER twice, so our option was to have them go to the ER in the morning and to prove the case 'urgent/emergent,' costing the insurance company another ER visit charge."

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Elizabeth Struble, MD: “I have a patient who was on a generic brand of an antidepressant medication. Last year, their insurance required that they, instead of taking the generic, needed the brand-name medication. Unfortunately, at that time, our local pharmacy did not have the brand name available. The patient ended up paying out-of-pocket at a different pharmacy, and in the new year we tried again. I sent the generic, for which the insurance company required a prior authorization to approve the generic. The prior authorization was denied, stating that the patient needed to take the brand-name medication. Once I submitted the brand-name medication, another prior authorization was required. In the meantime, this patient had been without this medication now for over a week. The generic version of this medication was fairly inexpensive, but still more than the patient would have paid had their insurance approved the medication as they had in the past. This unfortunate patient’s situation is still not resolved.”

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Sharon M. Moe, MD: “An (elderly patient) who had progressive CKD and chose not to undergo dialysis, and instead continue to live their life to the fullest they could. The patient was quite anemic, as is usual, with end-stage kidney disease and shortness of breath. They needed injections of erythropoietin, a hormone that is given to nearly all patients who choose dialysis. From order to receipt was two months due to back-and-forth prior authorization for the GENERIC form of this injection. That's two months of their life they could NOT do the few things they wanted to do before passing due to being short of breath. This is just wrong.”

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Erin McDonald, MD: “I had a patient who presented with progressive shortness of breath, cough, and weight loss several months after having COVID. The patient’s chest X-ray was abnormal, and a subsequent chest CT showed a 4.2-centimeter left lower lobe mass with bilateral noncalcified pulmonary nodules and intralobular septal thickening likely reflective of bronchogenic carcinoma with metastatic disease and possible lymphangitic spread of the tumor. A radiologist recommended a PET/CT. There was notable mediastinal and upper abdominal adenopathy. I referred the patient to pulmonology for biopsy and oncology and ordered a PET/CT. The PET/CT was declined by their insurance because their tumor was not over 8 centimeters, and we did not yet have a tissue diagnosis, despite my peer-to-peer. This patient with Stage 4 lung cancer, which spread into their chest, abdomen, and pelvis, had to pay for their own PET scan.”

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Carolyn Warner-Greer, MD: “I work for a community mental health/FQHC where we are a safety net for under-resourced patients who are impacted greatly by social determinants of health. Many of my patients suddenly need PAs for medications they have taken for years, that are generic, and that treat chronic illness that does not spontaneously remit. Pharmacies are understaffed and do not do a good job of alerting us to the need for a PA. The typical situation is seeing the patient in a month (or in the emergency room or our inpatient hospital) after a relapse of their illness without medication. This is always unnecessary and eventually costs Medicaid more in resources!” 

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Brittany Huynh, MD: “Teen patient with terrible arthritis affecting most of their joints despite trials of multiple medications. Prescribed the patient a new biological medication (which was the last option as it doesn’t cause liver side effects and the patient has liver disease). The first prior authorization was denied after waiting about 45 business days to hear back. I wrote a letter of medical necessity and it similarly took quite a while to hear back from insurance. It was eventually approved, but took three to four months to do so. Meanwhile, my patient is in high school and having difficulties walking and using their hands for schoolwork (difficulties holding pens/pencils). Delaying coverage of medications to save money at the expense of patient health is completely unacceptable.”

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Allon Friedman, MD: “I was taking care of several patients at (a local hospital) who required rituximab infusions for autoimmune kidney diseases on an urgent basis. They were denied by the insurance company and so followed the prior authorization by calling a specific number. If I remember correctly, I was faxed a document to complete that I filled out and sent back. The document was rejected. I must have spent a few hours calling and leaving messages. The delays in getting this medicine were unconscionable. Not only was this an extremely frustrating process but one of my patients had a pulmonary embolus while waiting for approval, putting his life at risk.”

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Cassandra Curtis, MD: “All day, every day, my MA deals with prior authorization for the newer migraine medicines that are branded. Some insurances require re-authorization every three months even though the patient has been on the medications for years. As if this isn't enough, when she submits my note to justify why the patient needs this newer and more expensive medication, my note documents that the patient has failed A,B,C, D drugs. The first PA is often denied, and the form letter states that the patient has to fail drugs A, B, C, D. So then my MA has to resubmit my note -- this time with the justifying statement circled and highlighted. This often delays patients getting their medications on time and costs my office precious time that could be spent on patient care. All day -- every day.”

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Thank you to the following physicians who have shared their names and stories with ISMA, and the dozens of others who have chosen to remain anonymous. 

Adam Amos, MD Daniel Armounfelder, MD Peter H. Baenziger, MD Jeffrey Barr, MD Scott Curnow, MD Cassandra Curtis, MD Carrie Davis, MD Diane Donegan, MD Jana Sapkar Dukleski, MD Karen S. Evans, MD  Richard Feldman, MD John E. Francis, MD, FACS Allon Friedman, MD John Fye, MD Teresa Greiner, MD Sam Horton, MD Brittany Huynh, MD  Dorothy Klingmeyer, DO Lois K. Lambrecht, MD Kyle Littell, MD William Marcrum, MD, FAAFP Suzanne Martini, MD Erin McDonald, MD Andrew M. Miller, MD  Sharon M. Moe, MD

Douglas Morrell, MD Douglas Neeld, MD Tamara Nelson, MD  Mercy Obeime, MD Grant J. Olsen, MD, FAAP, FACP A. Brooks Parker, MD Ann Patterson, MD Christina Pinkerton, MD Sarah Perryman, DO  Matthew Priddy, MD Christine Riley, MD Walter Roberts, MD Daniel C. Roth, DO Andrew Skinner, MD Jeffery J. Soldatis, MD Elizabeth Struble, MD  Gregory Swartz, DO Rachel Trupe, MD  Alexander Waldherr, DO Carolyn Warner-Greer, MD David Welsh, MD Danielle Wiese, MD Chris Wilson, MD Margaret Zelasko, MD