My company switched from BCBS to Aetna this year. I’ve been on a biologic for several years due to a genetic condition. Aetna denied it and then when the doctor asked for an urgent appeal they said it wasn’t urgent because it wouldn’t kill me - it actually would. They only approved it for 6 months and then we had to go through it again. I ended up getting my elected officials involved and then the state’s attorney general. Then I flared because of the stress. Thanks Aetna!
Mu mother had a similar experience with a medication. It is a pain when we go get refills but are then denied because it gets stuck in a authorization hell. Needs state and insurance authorization. She went 3 weeks without it once because of that. Important cancer medicine but luckily not a medication that'll kill her in the short run without it.
Oof, I'm sorry. I was on Aetna for a few years until they pulled out of my state, and my Prior Auth experience was them deciding I didn't *really* need those psych meds, after all I'd been on them for five whole years already! My psychiatrist was not pleased. They were replaced by Geisinger, who have been better in.. basically every way, it's kind of stunning. I hope you can get similar relief. :c
Not Aetna, but had something similar happen with an almost-emergency surgery... It was extremely urgent and got scheduled for 48 hours out. We called insurance and got it approved beforehand. Six months AFTER THE SURGERY, insurance denied it because it... wasn't actually an emergency? Wasn't strictly necessary? I'm not sure they went so far as to call it elective, but boy, they were implying it. I had a 20cm growth in my abdomen, so I guess TECHNICALLY I wasn't going to IMMEDIATELY die if I didn't have the surgery right then, but there were serious concerns about A, it being cancerous (in fact, my surgery was performed by an oncologist) and B, it rupturing and causing a dangerous infection. And again, I saw the doctor and was sent to surgery within 48 hours. It did not seem at all like I had a choie in the matter. So I'd say it wasn't exactly elective. But I guess I'm not a medical professional. 🙄
Man prior authorizations are the actual bane of my existence. I'm in stage 4 kidney failure and the number of times my nephrologist has had to fight with my insurance company is insane. If you pay for insurance, and they're trying as hard as they can not to pay for anything, then why do they exist?
Insurance-companies exist to make money by appearing¹ to make promises to contribute to costs when things go wrong. (1) when you have patience of an angel and time of an eternity to read all the fine-print the promises are hollower than the holiest Swiss cheese... Hope you persevere!
If you've watched his previous content I feel like they'll pay for something at some point because they have to keep you alive. You're a 'flesh covered bag of money' But really, I wish you and other Americans didn't have to go through this. But as a foreigner, why do you pay an insurance company if they don't finance your healthcare?
Non-US here - why has no one gone Postal on a healthcare Executive because they denied treatment? You guys shoot each other for far less important things like parking spaces and who's 'turf' you're on 🤷♀🤔 Are they exempted like in The Purge or something??
The insurance companies decided there’s a cheaper therapy option. Usually one that’s less effective, has nasty side effects, and/or costs them nothing. (Like literally- most generic drugs insurance companies pay less than $2 for.)
Yeah I had to get a prior authorization for a CT scan to check if my BRAIN WAS BLEEDING. The scanning facility was great and fast tracked it for me and it still took a day to get the ok.
I work in radiology imaging authorizations, and this is extremely accurate. And i love what i do... because i get to take insurance companies to task every day and push them to foot the bill. We all love Texaco Mike btw.
While I have you here, I feel I speak for all of us when I say Bill deserves a happy ending for all the torture he’s put up with through the years. Maybe like a residency graduation video? 🤞
@@aaliyahkishore246 thanks man. Cause Bill has earned it and as a PGY 2 now, I stand with him and understand his struggle. We all were or will be Bills at some point.
“Why do i even work here?” The reason United Healthcare hired Jimothy is because they LOVE suffering. Every time Jimothy is appalled by their evil, they feel absolutely incredible.
You've solved the mystery of how the execs can do all this and live with themselves! They are eldritch beings who feast on pain and drink fear and sorrow like wine. So uh... anyone know how to defeat ancient evil from before time as we know it?
As a German doctor who works in a system where your (mandatory and statutory) health insurance card basically provides a flatrate for medical care, I have a hard time imagining how it must feel for US physicians to practice in an environment where every decision they make - even and especially if its medically sound - can financially devastate their patients. That must be extra hard, and practicing medicine is hard enough as it is.
Most providers don't even actually know anything about billing. They have no idea what the bill could be, or who we should expect it to come from, or when. They *can* tell us (and require us to sign a form before they'll even see us) that anything insurance doesn't cover we will have to figure out how to pay for. The good ones DO fight against denied preauthorizations, though.
So much time and money is wasted when medical providers have to spend time on the phone arguing with insurance companies. My mom used to do it all the time to try and make sure those prior authorizations went through and her patients could get care. The fact that she worked in a cancer hospital and the treatments in her specialty actually are almost always effective just runs salt in the wound. There was absolutely no good reason for insurance to deny payment for the prescribed treatment, but they still had to waste her precious time arguing about it.
Thanks for trying to imagine. It is so incredibly frustrating. So much wasted time and effort to get an imaging study or medication that is standard of care. It’s the result of corruption - insurers donate money to politicians and then use their influence to persuade them to not regulate how they do business. Every day I think about quitting medicine, but then I think about my patients.
I have severe intractable migraines. The neurologist wanted to send me to the hospital for IV medications during one episode, but needed a prior authorization. The insurance company said they had the right to take up to seven business days to make a decision; they took every single day of that right. Seven business days and two weekends later -- 12 days total -- they denied the treatment. The reason was they had no idea if I still had a migraine after so many days. The neurologist's office responded that they did have a way to know since they had been sending requests marked URGENT every single day. The insurance company responded that they had no way to know if it was the SAME migraine, so still denied. The neurologist told me to go to the emergency room; the medication wouldn't be as good, but the ER could treat me without a prior authorization. The insurance company paid for it, but they sent a letter telling me the emergency room is only for emergencies and I should have gone to my doctor for treatment since I had been sick with the migraine for so many days. So now they had a way to know it was the same migraine??? That was the second time they had done something like this, the first being the migraine episode right before this one. That time they said they had five business days to make a decision. Five business days and a three-day holiday weekend, to be exact. I should have called the doctor for IVs a few times since then, but I didn't because what's the point? So yeah, they've more or less won with me.
Oof, sorry to hear you also have to suffer intractable migraine. Insurance hates paying for anything migraine related because you can't prove you have the condition because it's symptom based.
Utterly disgusting. I'm so sorry. Insurance claims for pain conditions are especially difficult because you can't technically "prove" it's as bad as you say it is. I had to take a leave of absence from work a few months ago because I had to change medications and my pain got out of control... and Insurance refused to pay a dime because I couldn't prove that I was actually in pain. Despite a whole pile of paperwork from various doctors backing me up. I genuinely wish sometimes that there were a way to just... trade bodies for a day. Or a week, or a month. Let them suffer through what we go through EVERY SINGLE DAY and then try to tell us it's not bad enough to treat. 😑
Next time bring a gun. This is America and apparently guns have all the rights and care. Tell them it's head hurts and if it doesn't get treatment it may pop off
My daughter has a genetic clotting disorder that has caused so many PEs, they stopped counting at "several hundred," years ago. She can't take blood thinners in pill form because she has severe Gastroparesis and doesn't process nor absorb most things. So she has to take Lovenox. The insurance requires a prior authorization every 90 days! This isn't going to suddenly disappear. Said clotting disorder is rare enough that it made the criteria for our state's Rare and Expensive Medical Program.
My mom about 15 years ago had a blood clot and due to a previous gastric bypass she wasn't absorbing oral anticoagulants at a consistent rate, her numbers were totally chaotic. So they put her back on lovenox. Her insurance denied it, and all the appeals. So she applied for the manufacturer's "I need this but can't get it under insurance" program - they gave it to her free of charge for 6 months. Keep this in mind if you have more issues!
As a pain clinic patient for 20+ years, all I can say is, "I love you Dr. Glaucomflecken!" You feel my pain....not the constant back pain necessarily. But the constant pain called US Healthcare. Thank you for understanding.
I'm so sorry. I'm also a pain clinic patient and boy, does insurance like to give us the runaround. My current favorite thing is nerve ablations - my insurance covers the doctor and the anesthesiologist, but not the outpatient surgery center where I get it done? Even though it's owned/ran/performed by the same doctor and according to the pain management contract, I'm not allowed to go anywhere else?? So it's too expensive for me to afford right now. 😂
My ophthalmologist had to describe my condition to Blue Cross as if my head was going to explode like Scanners in order to get them to authorize a treatment that she had been using for twenty years (PDT). It was standard practice in the field but insurance companies were still digging in their heels.
This is all because of some court ruling banning different pricing. Before that, the hospitals were able to charge the uninsured people the non-insurance-inflated lower prices. I recall this happened in the 1970s. My guess is that it is based on the 1936 Robinson-Patman Act, applied in shrewd way. With the uninsured declared a pariah like that, the point of having a health insurance is subverted. Now instead of you choosing to get an insurance when you actually WANT or NEED IT, you are fined by the gov because you are not giving money to its insurance lobby buddies. The gov is basically the cartel enforcer and a goon in the field of medical insurance. An ironic quote: "The amendment to the Clayton Antitrust Act prevented unfair price discrimination for the first time by requiring a seller to offer the same price terms to customers at a given level of trade." The phrase 'price discrimination' in the post-1700s corporate America means "greedy big corpos cannot price compete without the gov crushing the small biz with excessive regulatory laws."
I love that we are 5 days into this thing and Jimothy is already burnt out and dishevelled. Doesn’t even give his exacerbated “what” at the beginning anymore.
"What gives *you* the right to restrict people on their health? Do YOU have a decade of medical training?" Lawmakers and Health insurance companies: "lol no. But how 'bout I still do the restrictions anyways?"
I remember when it was just really expensive stuff with cheaper alternatives or procedures that might be cosmetic or elective that might need a PA. I even worked at a pharmacy insurance carrier in 2010, and PA's were used sparingly. Now it's EVERYTHING.
I have to get prior auths for my generic extended-release methylphenidate I’ve been taking off and on for 20 YEARS and will need for the rest of my life, or at least until my blood pressure forbids it. Because ADHD doesn’t go away. 😑
I referred my patient to a tertiary center for a much needed repair of her colocutaneous fistula (she has cancer and her gut has made a hole burrowing out to her belly). The insurance company denied, told me to send her home with wound care first to see if it heals. I’m keeping her in the hospital 5 days past their “suggested discharge”, argue with them everyday, some days feel like crying. I hate this system with a passion.
Prior authorization costs the insurance company more than if they just paid for the procedure in the first place. Took my adult kid to the hospital, gall stones. Gall bladder needed to be removed. Insurance said it needed to ve authorized forst, but couldn't be authorized by the hospital. It had to ve requested by their primary physician. It took 3 weeks to get an appointment with the primary. She sent in the request for authorization. A week later we were back in the ER, it was now sn emergency because a stone was impacted. The nearest doctor trained for that was more than 200 miles away. So yeah, a 200 mile ambulance ride and a 4 day stay in the hospital in the other city for something that would have been just an overnighter had it been done at the local hospital. The pre-authorization came the day after we got home from the hospital. So all that extra time and cost just so they can pre-authorize a normal and needed procedure.
God, I feel this. I ran short on u200 insulin on my 90-day supply and the insurance would not fill an emergency order of u100 to cover the gap until the regular u200 was available again. Said they needed a prior authorization to fill an insulin order for a chronic health issue that was on my record for 30 years. Christ I am still angry at this practice.
I have T1D-I have been lucky enough to not be in that situation, but my god . . . maybe you could ask your doctors to write your Rx for more insulin than you actually use so you can build up an emergency supply? The point is, you shouldn’t have to do these stupid workarounds in the first place. I thought I would share this idea though in case it is helpful :)
My favorite is being told my medicine I've been taking for the past 2 years needs prior authorization, then waiting on hold for 30m only to be told that there is no prior authorization hold, then to wait another 30m to an hour while the insurance and pharmacy play phone tag before finally resolving the issue.
Even if it did require preauthorization it would have been denied the first time anyway. My daughter's first Auth for growth hormone was denied because while her endocrinologist summarized her karyotype test result, the insurance company wanted to see the actual lab report. The renewal Auth was denied a year later because they didn't feel that an updated growth chart that clearly marked her latest height and weight was her doctor reporting her latest height and weight to them. And did they either time contact the doctor? Nope. They sent me the denial via USPS. And because they didn't tell me why it was denied, I spent hours on the phone with them each time.
I'm kinda hoping this 30 Days thing is a slow buildup of Jimothy getting more and more fed up with the system until he explodes, punches his boss in the face, quits, and moves out to the country to work for Rural Medicine and Texaco Mike.
My doctor finally called and yelled at my insurance company because they kept denying my medication and I had already tried and failed with the other medication they covered. Wouldn’t you know they approved it.
I was in a similar boat recently... had already tried the alternatives and/or they were contraindicated. What ended up working was when my doctor prescribed a MUCH more expensive medication than the one we actuality wanted. The insurance company jumped to reverse their denial on that prior authorization, lol.
If you die, they get to keep all of the contributions for free. It is a waiting game for them. That incentivizes them to authorize only treatments that are worthless or cheap (to them, not to you, you'll still get charged) or pure placebos.
Watching with ice on at my Physical Therapist after a re-evaluation. DPT told me earlier we have to see if insurance will authorize more visits...my arm still feels like garbagio! THANKS US HEALTHCARE SYSTEM!
My insurance emailed me and was like "Hey, if you go see the doctor, or dentist, or ophthalmologist before the end of the year we'll give you this shiny badge" and I'm like "why? You won't approve of the care i need and i don't make enough to cover the co-pay"
Our plan gives a small discount for doing some preventative things like blood work and a yearly check - up but yeah what's the point when you still can't afford to fix whatever the screenings found?
Dr ordered MRI w/ contrast of my brain. Couldn't get the IV started, so they asked me to reschedule. Secondary insurance denied pre-auth for rescheduled MRI "because I just had one" even though it wasn't completed. Peer-to-peer fails because no really, I'd already had one, but they were referring to the one I'd had six months ago on my LEG so clearly another one was unwarranted. Turns out, primary insurance (who did authorize it) COVERED IT IN FULL the whole time. secondary denied their share of a ZERO DOLLAR copay. MRI provider still would not go through with it because there was a denied pre-auth on file. Finally got it straightened out and approved, but when I got to my appointment (after drinking lots of fluids!)... The order was expired And that is the story of how I have been waiting 5 months to get an MRI of my brain. I'm just thankful it's routine and not urgent
I feel the answer to your question, Jimothy, could spin off something like "30 days of student loans" or "30 days of labor market" or "30 days of housing".
I wast treated for PTC and metastatic carcinoma in August. Developed a Chyle leak requiring extended hospitalization and two more surgeries. I spent more time worrying about whether or not stuff was covered than getting better. Thank God my wife and medical team did take care of all that. But you never know until its processed.
My mother's insurance required prior authorization for Tamiflu, which has to be given within 24 hours of the onset of symptoms to be effective! We paid out of pocket.
I don't know it's a good or bad thing because it's forbitten in France now because of some side effect like Hallucinations and others. Is there other meds your mother can take ?
I think the worse scenarios are when the patients themselves have to call the insurance because of all the delays just to be juggled around between departments and be given a date that comes with no answer.
Routinely, insurance requires pre-auths for inexpensive medications for us. My daughter has necessary, life-saving meds that she has been taking for years, and they constantly delay the filling of prescriptions for pre-auths. Some of the meds only cost a few dollars if paid out of pocket, but we still have to go through the headaches and delays.
Yeah, it's confusing. My last insurance refused to pay for lidocaine, but approved Botox no problem despite being 6x the cost. My new insurance didn't even require a prior auth for Botox, but did require it for a $60/month medication. Make it make sense.
It's just...baffling. I'm getting an MRI tomorrow for a suspected brain tumour. The neurologist has been absolutely on the ball, arranging the MRI in only a week, and promising to get me urgent treatment, surgery and hospitalisation after she sees the scan results. I'm bloody terrified, but I'm confident that I'm being taken care of. If I lived in the US rather than France, how much worse would my odds of survival be? Could insurance companies actually delay or deny the MRI or surgery?
Yes, but remember...they say they are not practicing medicine. They aren't saying you can't have it; they're just saying they won't pay for it. 😢 For most people, it's the same thing.
I think I found the next best thing to Jonathan's head nod. The insurance company worker's "caring" smile and the zoom-in shot right away a naive statement from Jimothy
It would not be that bad if the gov did not force you to get insured. A person under 30 has no reason to insure anything, it is simply pissed away money statistically speaking. For example, the most common cause of death of people under 30 is accidents. I would be okay with insurance companies and their hospital goons charging whatever if I was free to not take it. ACA mandates one to take an insurance under the threat of a fine. People reported that with the mandate, the insurances became less covering and more expensive. In fact the insurance revenue rose by 97 %. The lobbying by insurance companies really paid off for them. "First, the ACA almost doubled insurers’ premium revenue in the individual market, which increased by 97 percent, reflecting the considerable increase in enrollment brought about by the law’s subsidies and market reforms. Overall, health insurers’ premium revenues increased 6.2 percent, including group enrollment. This indicates that employer sponsorship of health insurance did not drop substantially in 2014." -"How Has the Affordable Care Act Affected Health Insurers' Financial Performance?" [a research article], 2016
Yes, a thousand times, yes. My sister needed a medication near the end of her life. The doctor approved. The pharmacist had it. But the pharmacist said insurance had not yet approved - and she mentioned I could pay for it myself if I wanted to get it now. I asked how much a month's supply would be. Thirty-five dollars. THIRTY-FIVE F'N DOLLARS! I paid and walked out with the meds. I then told my sister's caregiver what had happened so she could the same things as I did. Not frustrating at all.
I had insurance tell me they wouldn’t cover my antidepressants I’ve been taking for a long time and you can’t just switch them without horrible side effects and there is no expectation that their cheap option will work. I’ve been taking these for decades and will at a high dose for the rest of my life or you know, die. So now I have “health insurance “ but pay out of pocket for meds. It was a straight up. “We will cover this for one month as a courtesy but after that you can just die. In a letter.”
Yeah, it’s inconvenient but it can be fought. It’s what I do for 40+ hours a week. What really helps is submitting journal articles or some sort of medical literature that backs up your points about the side effects and the potential risks of switching medications after being established on a successful therapy.
I am dealing with this at the moment. My doctor thinks thst i have X, the specialist thinks that i have X, i think that i have X, and we are all waiting for the insurance to not be able to worm its way out of giving my money back to pay for the diagnosis and treatment. They denied two of the best ways of diagnose X, and spproved the third one, but every step is a month of waiting while hearing lawyers and souless doctors trying to find a loophole.
My elderly friend has had a UTI for several weeks, and her insurance keeps denying her the only antibiotics to which she is not allergic. They denied it again even after the doctor completed prior authorization.
Just pay for the shit out of pocket ffs. Utis damage kidneys and she's just making it worse on herself. Yeah the cost sucks but she's being irresponsible about her health.
@@fourgrayskull6468 cheaper than a damaged kidney. She can submit a refusal response and have them re evaluate their decision. Her doctor can also arrange to speak to a physician within the insurance company. There's recourse. She can also go to the emergency room and force the insurance company's hand.
@@fourgrayskull6468 Several thousand dollar antibiotics seems wrong. I'm used to antibiotics so cheap that I pay full price because they're cheaper than my co pay.
So, let's ask ourselves what is the solution?! I've lived in Europe. I won't say that socialized medicine is perfect, but it's a hell of a lot better than what we have. We would also have to start treating many of our social ills as public health issues. Guns - public health issue, because of the cost of the long-term care of a gunshot survivor is often horrific. Drugs - a public health issue, because the cost of untreated addiction is causing us to billions. Domestic violence - it ravages our country and our medical system.
Don't forget the big one - poverty. It cuts your life short and is a major source of stress that affects mental health. In the US, poverty is so life shortening that the difference in life expectancy between the top 1% and lowest 1% is 14 years.
We have socialized medicine in the US, too! When people can't pay their bills the hospitals don't just write them off. They raise rates on everyone else to cover it. So we have the WORST possible version of socialized healthcare.
The solution is for the government to stop letting insurance companies get away with so much, but not to focus so much on universal healthcare until we do (let's be honest, the US is not in a good position for that kind of change, not unless we want something comparable to or worse than our public education system.) I honestly feel like the subject of universal healthcare is one of the big reasons nothing happens, there are obvious negatives people can latch onto for counterpoints and prior attempts haven't been so great, so it's an option that is currently going to go nowhere. Instead we need to focus on the exploitative nature of healthcare and create an argument that is much harder for private healthcare to create opponents for. Private healthcare isn't necessarily a problem, and it has been a fairly decent system until the last decade or so, but once corruption took root it definitely became a big issue
@differnet You left out junk/fake food, alcohol, toxic chemicals, cigarettes, etc. Big pharma drugs kill over 100K a year, way more than guns do. The majority of gun deaths are suicides. Think they will shut down those anti-health industries and make life good for the peons so they don't kill themselves?! The solution: preventative medicine. That means a healthy lifestyle, using healthy/organic food, non-toxic personal care and cleaning products, nontoxic furniture and building materials, pure air and water, and saying no to booze, big pharma and street drugs, and tobacco products. It means being outside and exercising, instead of being a "couch potato" addicted to tech, porn, shopping, eating, focusing on genitals, and all the other anti-life "vices" and past-times of modern society. Who wants to end all of that to have good health and save money?! Too much "fun" to be had being unhealthy, "since we only live once", right?! Prevention cuts sick care costs, but that does not make the corporate conies any money, is considered "boring", and people will live too long! The rulers take advantage of people not knowing or caring about healing and staying healthy using "alternative therapies" and lifestyle choices, addressing the root causes of disease. Disease is NOT the result of a drug deficiency or lack of surgery! Why should we all pay for poor lifestyle choices, for someone that chooses be ill and not healthy?!
@@homerman76 - You seem to be arguing for the Swiss system. It's paid for by private insurance, the insurance companies are regulated in what they charge and what they must pay for. The problem the US would have with it is that everyone is forced to buy it. All you need to do is take a look at how many drivers are uninsured in states that require insurance, and you know they won't be buying health insurance, either.
I have to get PAs for everything even with several allergies and multiple medication sensitivity on file. By default, I either pay out of pocket (-180, or 400 out of pocket every month while living at poverty level). My care is delayed by default. I honestly think you can change something. Jimothy can change things.
I work in billing followup for a multi hospital medical group. It saddens me and infuriates me that even when you have something authorized they can change their mind after they pay and forcefully take that money back years after the service. Thus leading to us having to fight tooth and nail to get paid again.
why *does* Jimothy work there? He's clearly not happy. (I mean, the video series does raise perhaps more important questions about the health system, but I don't live in the US)
And this is why he gets paid the big dollars, not as much as his boss of course, but they figure his ideas are worth paying just enough to offset his moral compass
@@mattsword41 I worked for a health insurance company because they were the only ones who called me back. They take advantage of under-educated people to act as meat shields for their manager's paycheck. Fun fact: In 2008, any company that had an HSA was one easily identified as a company that didn't give a shit about their employees at all. Now they're just normal and calculated on receipts?
learn about alternative options, like socialized medicine. get vocal about it; drum up support from others. research political candidates at your local, state, and federal levels. and vote, vote, vote for candidates who are a step in the right direction. is the process slow? yes. but that is the process.
Write to government officials about it (governors, senate, congressmen) and agencies that are supposed to be overseeing and regulating this crapshow. Help a disabled person write THEIR complaints, as they've been deeper in the system than most anyone and abandoned by it and many are too burdened by poorly and untreated health problems to do so. Sounds like a challenge, but there's this nifty little tool that's been pretty hot lately than can write things for you in whatever style you want that maaaaayyyy save a lot of time. What's it called...? ChateauGDP? Chat something something? 😉😏
Also, another comment suggested that once this series is complete, we all start emailing/tweeting/etc the playlist link to every Congressperson in the country at least once a month. Someone else suggested we include insurance company execs, and I suggested we aim for daily instead of monthly. There are more than enough of us to do it. I really think if a significant chunk of this fandom jumps on board and does even just a small bit of spamming it and we aim to make the flood last a few weeks, we'll be able to turn it into an internet phenomenon that gets media attention, which will be great for public awareness/education and also massively increase pressure on leadership. I seriously think it's a brilliant idea and we should do it. So here's hoping that takes off. It's one of the few things us people-at-the-bottom can do.
I work as a financial counselor for a major hospital. Patients without insurance have to either prepay $300 for a specialist visit or procedure, or have to apply through us to find some other way to pay (like Medicaid, charity services, etc.) It causes no end of frustration when we have to call a patient and a facility the day of their appointment and tell them it's not approved and they have to cancel or pay because we didn't get the paperwork from the patient on time. Oh, and I live in a state without expanded Medicaid, so good luck going that route if you're not disabled, a child or have children, or over 65. Thanks, General Assembly.
I hate how right you are. My life is now so painful and nonproductive filling out endless forms for PAs of things that I wouldn’t have ordered if they weren’t necessary. And don’t get me (or us) started on pharmaceutical middle management. 😡🤬
I wonder what would happen if all the office workers at these health insurance companies walked out and quit! Although many of them may actually be trying to help patients find ways to get authorization thru the labyrinth of bureaucracy. Would be best for govt to just, you know, stop letting insurance providers practice medicine without a license!
I used to do all the PAs for the surgeon i worked with (am a PA). The cool thing is pretty much all the insurance Docs i talked with were understanding and approved everything. Never had to jump through hoops.
But one could argue that 1) prior authorization is, in and of itself, a hoop and 2) the requirement to jump through it is, by definition, a delay in receiving care/treatment. Which they are. And it is utterly unjustifiable in cases of chronic conditions where an established and ongoing treatment has been in place for years (if not decades) yet still requires PA every few months throughout the year, every year.
As a Dermatology Scribe, if a patient comes in with a rash we basically have to spin the roulette wheel for “which corticosteroid is covered by insurance”. Sometimes they come in for poison oak or similar and we want clobetasol or betamethasone (two of the strongest, class 1) and the insurance responds “have you tried hydrocortisone (Class 7, over the counter)? Lots of fun stuff. The mail order or specialty brand names/ biologics I can understand but sometimes it’s a hassle just to prescribe doxycycline for a MRSA infection…
I was denied prior authorization for PT after my 6 week post partum checkup. I began doing PT in the 3rd trimester for pregnancy related pain affecting my mobility, & that prior authorization was approved. Then I had the baby, and was healing. But when I needed to resume PT after my 6 week post partum checkup, the order had expired, and for no reason whatsoever, my insurance denied the new prior authorization for the same location. UHC insurance told PT that I hit my limit of PT visits for the year (36)… but I did not. I had 6 total with the last 2 not covered… Then UHC told me that additional records were needed, and yet refused to clarify WHAT could possibly be needed as my midwives and PT said they sent medical records. So my midwives called to see what was still needed and this time UHC said that the PT was not in network & that I hit my limit of visits. (It is in network). I call UHC and was told again that my visit limit was hit, so I appealed with urgency because I cannot lift my baby well. UHC calls back the next day to indicate that they will not actually review my appeal with urgency, rather in 3-4 weeks, and that they will use my midwive’s appeal in their system rather than mine because the medical records are attached to hers. I already had to cancel that week’s PT… I insist on urgency & that my statements be included in the appeal along with the medical records, as it was a false dilemma to feign as if they couldn’t be combined, and let them know I will be filing a BBB report if antics continue (as UHC likes to hang up on patients, feign confusion, talk through a tin can etc., anything to provoke you into giving up). Suddenly within 24hrs I am approved to resume PT. 😑
Insane is a bit extreme. Maybe unhinged is a good fit like you slowly turn into a robot incapable of feelings and the only thing that drives you is clocking out as soon as it hits 5 nothing more coz if you sold your soul might aswell not overwork.
Hahaha, love it when the medical team says that due to his latest test results my 4yo nephew now urgently needs a specific medication in order to live and the insurance company is like "but does he really?" and then takes a month to authorize the injections, and we spent that whole time fingers crossed that his condition wouldn't rapidly deteriorate before we could treat him.
@@leo_warren ahh yea. I get that new high costing drugs, especially biologics need a cost:benefit analysis beforehand until the price goes down but thankfully super rare. Obv not ideal for the patient that isn’t sure if their treatment is covered especially when being used to not having to worry about such things for the vast majority of health issues. It does suck when a patient reaches the limit of what the nhs can offer but as you said, thankfully it’s rare
@@leo_warren biologics have been such a good break through for treatment. Sorry you had to wait so long for them to be preauthorised. I’m a med student so appreciate you informing me about the preauthorising. This stuff won’t get taught to us until we’re higher up the doctor chain. Hope the treatment is going on for you
your portrayal of health insurance reps both having 0 empathy and 0 medical knowledge is spot on. ever since i was little my mom and i have had many fun arguments with health insurance representatives over why i should get supplies for my t1 diabetes covered. one time i called them asking why my insulin prescription, you know, the thing my body doesnt make and i will literally die without, suddenly had a rather expensive copay, and i explained that im supposed to get it for free and always have, and this person, word for word, told me "why should you get it for free?" before i snapped back with "because i NEED IT TO LIVE", and then i had to switch to a different brand anyway that worked just different enough to where it impacted my blood sugars. on top of all that, when I was first diagnosed as a toddler, we couldnt even get insurance coverage for anything during the first year or so because of the "pre existing condition" crap at the time.
Prior authorizations wouldn't have to he a thing if hospitals didn't operate as profit centers. But since hospitals encourage (reward) doctors to run expensive and often unnecessary procedures and tests, this is what we get in response. So, yes, basically the insurance company is saying "prove you actually need this", because they know what is up. It's a two sided problem.
I encourage all in this comments section to contact your representatives in congress and the president and forward this RUclips video to them. I was able to Google how to do it and post it to both my representative and the president while sitting on the porcelain throne. The internet makes this quick and easy to do.
Yes, of course. NICU patients are fine to wait for a day or two before being admitted... No problem. I hope they do the right thing and cover this for you.
During my career in medicine, I have seen doctors change from using their sound medical judgement when ordering tests and medications - to doctors using "shotgun medicine" - where they order virtually every test, all at the same time and prescribe medicines in the same way. It is a liability issue. The lawyers have corrupted the system just as much as the insurance companies have.
That last line, like my insurance requires prior authorization for vitamins and I had severe deficiency, the prescription was less than $10 (still not something I can afford as I'm a college student) and the doctor's office told me they only do prior authorizations if the prescription is hundreds of dollars and there's no alternative The current healthcare system in the United States is literally killing people to save pennies
In spring 2022 my son required gall bladder removal. He called me on a Friday said he was in awful pain…he was in this pain all weekend, Monday he saw a physician to schedule the surgery. That evening he died at home. I thought it should have been taken care of right away. I wonder if “prior authorization” was the culprit. It’s a sick, weird business health insurance. Why can’t we have healthcare like most modern countries?
@@tammywilshire4170 Thank you. Gallbladder trouble is in our family. I had mine out at 23 after my son was born. I was skinny as a rail. He was an adult. He called me about the pain, but said he’d see a doctor the next week. He had been diagnosed in an emergency room . It’s just so sad, 41 with a daughter to raise. I think they should have done the surgery as emergent. It’s done, he won’t come back. But this stuff with the insurance is just awful. Thank you for your condolences.
That's not what that is. They only approve a few treatments at a time because the patient may have another insurance later. The prior authorization is stronger than insurance cancellation.
All the while creating a ton of extra work for doctors and pharmacists, which distracts us from being able to provide care to other patients, all without any sort of billable or reimbursable compensation. Larger institutions have to fund entire prior auth departments because of the amount of extra work this creates. It's lovely.
So, what if the insurance company additionally had to pay out in the case of their clients dying? Is this idea crazy? Already implemented somewhere? I feel like giving them an incentive to keep their patients alive would go a long way.
I have a brain shunt for hydrocephalus, and every few years I need to go in for a CT scan. But first I need to wait for prior authorization to go through before I can get this necessary routine procedure to make sure something isn't wrong that could potentially kill me.
If prior authorization almost pro forma you've got a problem. The point isn't to see if the patient needs it. The point is to look it up in the table and see if it's covered or not.
On the 5th day of September, Dr. Glaucomflecken taught, Prior Auths practice med'cine with no license!! Co-payments punish, Co-insurance varies (but invariably sucks), Deductibles are scams, And how monthly premiums make us distraught
Currently paying 250/month for a specific medication out of pocket because my ins won't cover it without a prior authorization despite covering the immediate release version of it that would leave me unstable. Go insurance!
United Healthcare sent me a denial letter a few days ago denying a spinal procedure. The same procedure that was done two weeks ago after their initial approval. Their “in-house experts” reviewed the matter and determined I didn’t need it. So now prior authorizations mean nothing.
![Things you don't say out loud in academia [9 open secrets]](/img/1.gif)
Starting October 1st, the 30 Days playlist needs to be Tweeted, texted or emailed to every member of Congress on a monthly basis.
Daily.
@@nancylindsay4255🎉
and EVERY insurance company CEO, CFO, CIO, CMO, and any other C-O you can think of.
@@nancylindsay4255hourly
Annoy them until change happens I love this plan
My company switched from BCBS to Aetna this year. I’ve been on a biologic for several years due to a genetic condition. Aetna denied it and then when the doctor asked for an urgent appeal they said it wasn’t urgent because it wouldn’t kill me - it actually would. They only approved it for 6 months and then we had to go through it again. I ended up getting my elected officials involved and then the state’s attorney general. Then I flared because of the stress. Thanks Aetna!
Mu mother had a similar experience with a medication. It is a pain when we go get refills but are then denied because it gets stuck in a authorization hell. Needs state and insurance authorization. She went 3 weeks without it once because of that. Important cancer medicine but luckily not a medication that'll kill her in the short run without it.
Oof, I'm sorry. I was on Aetna for a few years until they pulled out of my state, and my Prior Auth experience was them deciding I didn't *really* need those psych meds, after all I'd been on them for five whole years already!
My psychiatrist was not pleased.
They were replaced by Geisinger, who have been better in.. basically every way, it's kind of stunning. I hope you can get similar relief. :c
@@popenieafantome9527jeez
Not Aetna, but had something similar happen with an almost-emergency surgery... It was extremely urgent and got scheduled for 48 hours out. We called insurance and got it approved beforehand. Six months AFTER THE SURGERY, insurance denied it because it... wasn't actually an emergency? Wasn't strictly necessary? I'm not sure they went so far as to call it elective, but boy, they were implying it. I had a 20cm growth in my abdomen, so I guess TECHNICALLY I wasn't going to IMMEDIATELY die if I didn't have the surgery right then, but there were serious concerns about A, it being cancerous (in fact, my surgery was performed by an oncologist) and B, it rupturing and causing a dangerous infection. And again, I saw the doctor and was sent to surgery within 48 hours. It did not seem at all like I had a choie in the matter. So I'd say it wasn't exactly elective. But I guess I'm not a medical professional. 🙄
I think the state health insurance I’m on rn is switching from BCBS to Aetna soon 🥲
Man prior authorizations are the actual bane of my existence. I'm in stage 4 kidney failure and the number of times my nephrologist has had to fight with my insurance company is insane. If you pay for insurance, and they're trying as hard as they can not to pay for anything, then why do they exist?
Because apparently inserting a profit motive into something like healthcare is good. Somehow. Because reasons.
It's all about $$$ and not the patient. As in profit $$$. 🙄😕
Insurance-companies exist to make money by appearing¹ to make promises to contribute to costs when things go wrong. (1) when you have patience of an angel and time of an eternity to read all the fine-print the promises are hollower than the holiest Swiss cheese...
Hope you persevere!
If you've watched his previous content I feel like they'll pay for something at some point because they have to keep you alive. You're a 'flesh covered bag of money'
But really, I wish you and other Americans didn't have to go through this. But as a foreigner, why do you pay an insurance company if they don't finance your healthcare?
Non-US here - why has no one gone Postal on a healthcare Executive because they denied treatment?
You guys shoot each other for far less important things like parking spaces and who's 'turf' you're on 🤷♀🤔 Are they exempted like in The Purge or something??
I had to get prior authorization for a medical condition I've had for years that like 100M Americans suffer with. Like wtf?
But does that condition REALLLY actually exist?
Sounds like a pre-existing condition to me.
The insurance companies decided there’s a cheaper therapy option. Usually one that’s less effective, has nasty side effects, and/or costs them nothing. (Like literally- most generic drugs insurance companies pay less than $2 for.)
Yeah I had to get a prior authorization for a CT scan to check if my BRAIN WAS BLEEDING. The scanning facility was great and fast tracked it for me and it still took a day to get the ok.
@@TalabAlSahra - Only if the insurance company agrees that it exists.
I work in radiology imaging authorizations, and this is extremely accurate. And i love what i do... because i get to take insurance companies to task every day and push them to foot the bill.
We all love Texaco Mike btw.
If they fire you, promise to go interventional on the CEO okay?
While I have you here, I feel I speak for all of us when I say Bill deserves a happy ending for all the torture he’s put up with through the years. Maybe like a residency graduation video? 🤞
Commenting to get this comment to the top so he can see this
@@aaliyahkishore246 thanks man. Cause Bill has earned it and as a PGY 2 now, I stand with him and understand his struggle. We all were or will be Bills at some point.
Glau inspires me.. My parents said if i get 50K followers They'd buy me a professional camera for recording..begging u guys , literally
Begging..
Bill deserves to see the tulips again, but this time for real.
Bill will never graduate residency. Because he's Bill. The universe won't allow it.
“Why do i even work here?”
The reason United Healthcare hired Jimothy is because they LOVE suffering. Every time Jimothy is appalled by their evil, they feel absolutely incredible.
And every time he's disgusted by an idea of theirs, they know to go with it cuz it'll make them money.
@@BlackTigrIt’s like a moral compass, except you do the opposite of what it tells you :D
@@rofljohn23 "Oh he threw up out of shame from working here. That's a good sign."
Jimothy's parents were probably worse. "What do you NEED $5 for, exactly? Drugs? Is it drugs???"
You've solved the mystery of how the execs can do all this and live with themselves! They are eldritch beings who feast on pain and drink fear and sorrow like wine. So uh... anyone know how to defeat ancient evil from before time as we know it?
As a German doctor who works in a system where your (mandatory and statutory) health insurance card basically provides a flatrate for medical care, I have a hard time imagining how it must feel for US physicians to practice in an environment where every decision they make - even and especially if its medically sound - can financially devastate their patients. That must be extra hard, and practicing medicine is hard enough as it is.
Most providers don't even actually know anything about billing.
They have no idea what the bill could be, or who we should expect it to come from, or when.
They *can* tell us (and require us to sign a form before they'll even see us) that anything insurance doesn't cover we will have to figure out how to pay for.
The good ones DO fight against denied preauthorizations, though.
So much time and money is wasted when medical providers have to spend time on the phone arguing with insurance companies. My mom used to do it all the time to try and make sure those prior authorizations went through and her patients could get care. The fact that she worked in a cancer hospital and the treatments in her specialty actually are almost always effective just runs salt in the wound. There was absolutely no good reason for insurance to deny payment for the prescribed treatment, but they still had to waste her precious time arguing about it.
Healthcare is a thing for the wealthy. Not need to worry, most of us will never even have the hope of any medical care ever..
Thanks for trying to imagine. It is so incredibly frustrating. So much wasted time and effort to get an imaging study or medication that is standard of care. It’s the result of corruption - insurers donate money to politicians and then use their influence to persuade them to not regulate how they do business. Every day I think about quitting medicine, but then I think about my patients.
@@christawilliams8068on behalf of your patients: thanks for sticking it out, even though insurance is rooting against you ❤
I have severe intractable migraines. The neurologist wanted to send me to the hospital for IV medications during one episode, but needed a prior authorization. The insurance company said they had the right to take up to seven business days to make a decision; they took every single day of that right. Seven business days and two weekends later -- 12 days total -- they denied the treatment. The reason was they had no idea if I still had a migraine after so many days. The neurologist's office responded that they did have a way to know since they had been sending requests marked URGENT every single day. The insurance company responded that they had no way to know if it was the SAME migraine, so still denied. The neurologist told me to go to the emergency room; the medication wouldn't be as good, but the ER could treat me without a prior authorization. The insurance company paid for it, but they sent a letter telling me the emergency room is only for emergencies and I should have gone to my doctor for treatment since I had been sick with the migraine for so many days. So now they had a way to know it was the same migraine???
That was the second time they had done something like this, the first being the migraine episode right before this one. That time they said they had five business days to make a decision. Five business days and a three-day holiday weekend, to be exact. I should have called the doctor for IVs a few times since then, but I didn't because what's the point? So yeah, they've more or less won with me.
That’s disgusting, I’m sorry you’re going through this
Oof, sorry to hear you also have to suffer intractable migraine. Insurance hates paying for anything migraine related because you can't prove you have the condition because it's symptom based.
Utterly disgusting. I'm so sorry. Insurance claims for pain conditions are especially difficult because you can't technically "prove" it's as bad as you say it is. I had to take a leave of absence from work a few months ago because I had to change medications and my pain got out of control... and Insurance refused to pay a dime because I couldn't prove that I was actually in pain. Despite a whole pile of paperwork from various doctors backing me up.
I genuinely wish sometimes that there were a way to just... trade bodies for a day. Or a week, or a month. Let them suffer through what we go through EVERY SINGLE DAY and then try to tell us it's not bad enough to treat. 😑
Next time bring a gun. This is America and apparently guns have all the rights and care. Tell them it's head hurts and if it doesn't get treatment it may pop off
What you went through is infuriating.
My daughter has a genetic clotting disorder that has caused so many PEs, they stopped counting at "several hundred," years ago. She can't take blood thinners in pill form because she has severe Gastroparesis and doesn't process nor absorb most things. So she has to take Lovenox. The insurance requires a prior authorization every 90 days! This isn't going to suddenly disappear. Said clotting disorder is rare enough that it made the criteria for our state's Rare and Expensive Medical Program.
im so sorry your daughter has to go through that. i hope you all stay well.
That’s horrible
My mom about 15 years ago had a blood clot and due to a previous gastric bypass she wasn't absorbing oral anticoagulants at a consistent rate, her numbers were totally chaotic. So they put her back on lovenox. Her insurance denied it, and all the appeals. So she applied for the manufacturer's "I need this but can't get it under insurance" program - they gave it to her free of charge for 6 months. Keep this in mind if you have more issues!
It would be great if this series just unexpectedly starts a healthcare system political movement.
As a pain clinic patient for 20+ years, all I can say is, "I love you Dr. Glaucomflecken!" You feel my pain....not the constant back pain necessarily. But the constant pain called US Healthcare. Thank you for understanding.
I'm so sorry. I'm also a pain clinic patient and boy, does insurance like to give us the runaround. My current favorite thing is nerve ablations - my insurance covers the doctor and the anesthesiologist, but not the outpatient surgery center where I get it done? Even though it's owned/ran/performed by the same doctor and according to the pain management contract, I'm not allowed to go anywhere else?? So it's too expensive for me to afford right now. 😂
My ophthalmologist had to describe my condition to Blue Cross as if my head was going to explode like Scanners in order to get them to authorize a treatment that she had been using for twenty years (PDT). It was standard practice in the field but insurance companies were still digging in their heels.
This is all because of some court ruling banning different pricing. Before that, the hospitals were able to charge the uninsured people the non-insurance-inflated lower prices. I recall this happened in the 1970s. My guess is that it is based on the 1936 Robinson-Patman Act, applied in shrewd way. With the uninsured declared a pariah like that, the point of having a health insurance is subverted. Now instead of you choosing to get an insurance when you actually WANT or NEED IT, you are fined by the gov because you are not giving money to its insurance lobby buddies. The gov is basically the cartel enforcer and a goon in the field of medical insurance.
An ironic quote: "The amendment to the Clayton Antitrust Act prevented unfair price discrimination for the first time by requiring a seller to offer the same price terms to customers at a given level of trade." The phrase 'price discrimination' in the post-1700s corporate America means "greedy big corpos cannot price compete without the gov crushing the small biz with excessive regulatory laws."
I love that we are 5 days into this thing and Jimothy is already burnt out and dishevelled.
Doesn’t even give his exacerbated “what” at the beginning anymore.
Poor Jimothy isn’t going to make it all 30 days
You really hit the nail on this series. Thank you.
"What gives *you* the right to restrict people on their health? Do YOU have a decade of medical training?"
Lawmakers and Health insurance companies: "lol no. But how 'bout I still do the restrictions anyways?"
I remember when it was just really expensive stuff with cheaper alternatives or procedures that might be cosmetic or elective that might need a PA. I even worked at a pharmacy insurance carrier in 2010, and PA's were used sparingly. Now it's EVERYTHING.
I have to get prior auths for my generic extended-release methylphenidate I’ve been taking off and on for 20 YEARS and will need for the rest of my life, or at least until my blood pressure forbids it. Because ADHD doesn’t go away. 😑
I referred my patient to a tertiary center for a much needed repair of her colocutaneous fistula (she has cancer and her gut has made a hole burrowing out to her belly). The insurance company denied, told me to send her home with wound care first to see if it heals. I’m keeping her in the hospital 5 days past their “suggested discharge”, argue with them everyday, some days feel like crying. I hate this system with a passion.
Prior authorization costs the insurance company more than if they just paid for the procedure in the first place. Took my adult kid to the hospital, gall stones. Gall bladder needed to be removed. Insurance said it needed to ve authorized forst, but couldn't be authorized by the hospital. It had to ve requested by their primary physician. It took 3 weeks to get an appointment with the primary. She sent in the request for authorization. A week later we were back in the ER, it was now sn emergency because a stone was impacted. The nearest doctor trained for that was more than 200 miles away. So yeah, a 200 mile ambulance ride and a 4 day stay in the hospital in the other city for something that would have been just an overnighter had it been done at the local hospital. The pre-authorization came the day after we got home from the hospital. So all that extra time and cost just so they can pre-authorize a normal and needed procedure.
For every 100 of you.
2 get what you had
6 die
2 pay out of pocket.
90 just wait.
Every patient death is a win for health insurance
God, I feel this. I ran short on u200 insulin on my 90-day supply and the insurance would not fill an emergency order of u100 to cover the gap until the regular u200 was available again. Said they needed a prior authorization to fill an insulin order for a chronic health issue that was on my record for 30 years. Christ I am still angry at this practice.
I have T1D-I have been lucky enough to not be in that situation, but my god . . . maybe you could ask your doctors to write your Rx for more insulin than you actually use so you can build up an emergency supply? The point is, you shouldn’t have to do these stupid workarounds in the first place. I thought I would share this idea though in case it is helpful :)
My father, a physician, could have written this script fifty years! He asked the insurance rep what medical school they attended 😅
My favorite is being told my medicine I've been taking for the past 2 years needs prior authorization, then waiting on hold for 30m only to be told that there is no prior authorization hold, then to wait another 30m to an hour while the insurance and pharmacy play phone tag before finally resolving the issue.
I'm glad my doctor and pharmacy deal with that crap for me. Also why I try to get my refills submitted a couple of days before I actually run out.
Even if it did require preauthorization it would have been denied the first time anyway. My daughter's first Auth for growth hormone was denied because while her endocrinologist summarized her karyotype test result, the insurance company wanted to see the actual lab report. The renewal Auth was denied a year later because they didn't feel that an updated growth chart that clearly marked her latest height and weight was her doctor reporting her latest height and weight to them.
And did they either time contact the doctor? Nope. They sent me the denial via USPS. And because they didn't tell me why it was denied, I spent hours on the phone with them each time.
This series is devastating. You are wonderful. ❤❤❤
This comment right here. YES!
Jimothy is too good for them. I really hope he gets an arc with a happy ending (preferably one far _far_ away from the insurance industry)
He moves to Canada and lives happily ever after.
We need Jomothys on the inside fighting for us. They are angels fighting the evil known as US Health Insurance.
I'm kinda hoping this 30 Days thing is a slow buildup of Jimothy getting more and more fed up with the system until he explodes, punches his boss in the face, quits, and moves out to the country to work for Rural Medicine and Texaco Mike.
My doctor finally called and yelled at my insurance company because they kept denying my medication and I had already tried and failed with the other medication they covered. Wouldn’t you know they approved it.
I was in a similar boat recently... had already tried the alternatives and/or they were contraindicated. What ended up working was when my doctor prescribed a MUCH more expensive medication than the one we actuality wanted. The insurance company jumped to reverse their denial on that prior authorization, lol.
If you die, they get to keep all of the contributions for free. It is a waiting game for them. That incentivizes them to authorize only treatments that are worthless or cheap (to them, not to you, you'll still get charged) or pure placebos.
Watching with ice on at my Physical Therapist after a re-evaluation. DPT told me earlier we have to see if insurance will authorize more visits...my arm still feels like garbagio! THANKS US HEALTHCARE SYSTEM!
I'll keep watching these despite not living in the US
Feel free to encourage your political leaders to constantly shame our Senate and House members for not fixing any of this.
My insurance emailed me and was like "Hey, if you go see the doctor, or dentist, or ophthalmologist before the end of the year we'll give you this shiny badge" and I'm like "why? You won't approve of the care i need and i don't make enough to cover the co-pay"
Our plan gives a small discount for doing some preventative things like blood work and a yearly check - up but yeah what's the point when you still can't afford to fix whatever the screenings found?
Dr ordered MRI w/ contrast of my brain. Couldn't get the IV started, so they asked me to reschedule. Secondary insurance denied pre-auth for rescheduled MRI "because I just had one" even though it wasn't completed. Peer-to-peer fails because no really, I'd already had one, but they were referring to the one I'd had six months ago on my LEG so clearly another one was unwarranted.
Turns out, primary insurance (who did authorize it) COVERED IT IN FULL the whole time. secondary denied their share of a ZERO DOLLAR copay. MRI provider still would not go through with it because there was a denied pre-auth on file. Finally got it straightened out and approved, but when I got to my appointment (after drinking lots of fluids!)... The order was expired
And that is the story of how I have been waiting 5 months to get an MRI of my brain. I'm just thankful it's routine and not urgent
I feel the answer to your question, Jimothy, could spin off something like "30 days of student loans" or "30 days of labor market" or "30 days of housing".
I didn't think he could do 30 short segments but know that I think about it, he could probably do an entire year.
I wast treated for PTC and metastatic carcinoma in August. Developed a Chyle leak requiring extended hospitalization and two more surgeries. I spent more time worrying about whether or not stuff was covered than getting better. Thank God my wife and medical team did take care of all that. But you never know until its processed.
My mother's insurance required prior authorization for Tamiflu, which has to be given within 24 hours of the onset of symptoms to be effective! We paid out of pocket.
I don't know it's a good or bad thing because it's forbitten in France now because of some side effect like Hallucinations and others. Is there other meds your mother can take ?
Omfg
That's when you send the prior authorization request along tagged with "four hours to respond before it will be assumed to be an unreasonable denial".
I think the worse scenarios are when the patients themselves have to call the insurance because of all the delays just to be juggled around between departments and be given a date that comes with no answer.
Many years back, I worked for a very well-known insurance company. I found out, quickly, that they are amoral.
amoral = no morals, insurance companies are immoral, they know exactly the pain and suffering they cause, and are perfectly content doing so.
LMAO!!! Doc, you are really poking the bear with this series - and I LOVE IT!!
Routinely, insurance requires pre-auths for inexpensive medications for us. My daughter has necessary, life-saving meds that she has been taking for years, and they constantly delay the filling of prescriptions for pre-auths. Some of the meds only cost a few dollars if paid out of pocket, but we still have to go through the headaches and delays.
Yeah, it's confusing. My last insurance refused to pay for lidocaine, but approved Botox no problem despite being 6x the cost. My new insurance didn't even require a prior auth for Botox, but did require it for a $60/month medication. Make it make sense.
This is darker than the life of a radiologist
It's just...baffling. I'm getting an MRI tomorrow for a suspected brain tumour. The neurologist has been absolutely on the ball, arranging the MRI in only a week, and promising to get me urgent treatment, surgery and hospitalisation after she sees the scan results. I'm bloody terrified, but I'm confident that I'm being taken care of.
If I lived in the US rather than France, how much worse would my odds of survival be? Could insurance companies actually delay or deny the MRI or surgery?
Unfortunately, yes, they can and they do 😢😡
They can deny the mri and the surgery.
Actually, they will deny the mri and the surgery.
There are documented cases of that happening, daily.
Absolutely, and yes, they probably would require an auth for both the MRI and surgery. It's appalling
Yes. And they do. Repeatedly.
Yes, but remember...they say they are not practicing medicine. They aren't saying you can't have it; they're just saying they won't pay for it. 😢 For most people, it's the same thing.
These are so good, can't believe we're getting 25 more 😊
I think I found the next best thing to Jonathan's head nod.
The insurance company worker's "caring" smile and the zoom-in shot right away a naive statement from Jimothy
Once more a wonderful insight into greedy health insurance corporations. A good support and argument for universal health care for all!!
It would not be that bad if the gov did not force you to get insured. A person under 30 has no reason to insure anything, it is simply pissed away money statistically speaking. For example, the most common cause of death of people under 30 is accidents. I would be okay with insurance companies and their hospital goons charging whatever if I was free to not take it. ACA mandates one to take an insurance under the threat of a fine. People reported that with the mandate, the insurances became less covering and more expensive. In fact the insurance revenue rose by 97 %. The lobbying by insurance companies really paid off for them.
"First, the ACA almost doubled insurers’ premium revenue in the individual market, which increased by 97 percent, reflecting the considerable increase in enrollment brought about by the law’s subsidies and market reforms. Overall, health insurers’ premium revenues increased 6.2 percent, including group enrollment. This indicates that employer sponsorship of health insurance did not drop substantially in 2014." -"How Has the Affordable Care Act Affected Health Insurers' Financial Performance?" [a research article], 2016
Yes, a thousand times, yes. My sister needed a medication near the end of her life. The doctor approved. The pharmacist had it. But the pharmacist said insurance had not yet approved - and she mentioned I could pay for it myself if I wanted to get it now. I asked how much a month's supply would be. Thirty-five dollars. THIRTY-FIVE F'N DOLLARS! I paid and walked out with the meds. I then told my sister's caregiver what had happened so she could the same things as I did. Not frustrating at all.
My pharmacy tries to pull that with my thyroid medicine every so often. I've started just telling them I'll pay the $20 out of picket.
@@andreacook7431 So annoying but I'm glad you have the funds to pay for it.
Great if you can afford it. When it’s hundreds or thousands a month, that’s not usually feasible.
@@teleriferchnyfain Exactly my point. I'm not sure what I would have done had she said it would be $3,000. And I was worried that she would.
I had insurance tell me they wouldn’t cover my antidepressants I’ve been taking for a long time and you can’t just switch them without horrible side effects and there is no expectation that their cheap option will work. I’ve been taking these for decades and will at a high dose for the rest of my life or you know, die. So now I have “health insurance “ but pay out of pocket for meds. It was a straight up. “We will cover this for one month as a courtesy but after that you can just die. In a letter.”
Did you appeal? If not appeal and if that doesn't work, request an independent medical review from the.state.
Yeah, it’s inconvenient but it can be fought. It’s what I do for 40+ hours a week. What really helps is submitting journal articles or some sort of medical literature that backs up your points about the side effects and the potential risks of switching medications after being established on a successful therapy.
I am dealing with this at the moment. My doctor thinks thst i have X, the specialist thinks that i have X, i think that i have X, and we are all waiting for the insurance to not be able to worm its way out of giving my money back to pay for the diagnosis and treatment. They denied two of the best ways of diagnose X, and spproved the third one, but every step is a month of waiting while hearing lawyers and souless doctors trying to find a loophole.
My elderly friend has had a UTI for several weeks, and her insurance keeps denying her the only antibiotics to which she is not allergic. They denied it again even after the doctor completed prior authorization.
Omg
Just pay for the shit out of pocket ffs. Utis damage kidneys and she's just making it worse on herself. Yeah the cost sucks but she's being irresponsible about her health.
@@caitlinhs9670 it was several thousand dollars.
@@fourgrayskull6468 cheaper than a damaged kidney. She can submit a refusal response and have them re evaluate their decision. Her doctor can also arrange to speak to a physician within the insurance company. There's recourse. She can also go to the emergency room and force the insurance company's hand.
@@fourgrayskull6468 Several thousand dollar antibiotics seems wrong. I'm used to antibiotics so cheap that I pay full price because they're cheaper than my co pay.
I feel like someone like Jimothy needs to exist in these companies for legal reasons, but no-one is required to take what he has to say in board 😭
So, let's ask ourselves what is the solution?! I've lived in Europe. I won't say that socialized medicine is perfect, but it's a hell of a lot better than what we have. We would also have to start treating many of our social ills as public health issues. Guns - public health issue, because of the cost of the long-term care of a gunshot survivor is often horrific. Drugs - a public health issue, because the cost of untreated addiction is causing us to billions. Domestic violence - it ravages our country and our medical system.
Don't forget the big one - poverty. It cuts your life short and is a major source of stress that affects mental health. In the US, poverty is so life shortening that the difference in life expectancy between the top 1% and lowest 1% is 14 years.
We have socialized medicine in the US, too! When people can't pay their bills the hospitals don't just write them off. They raise rates on everyone else to cover it. So we have the WORST possible version of socialized healthcare.
The solution is for the government to stop letting insurance companies get away with so much, but not to focus so much on universal healthcare until we do (let's be honest, the US is not in a good position for that kind of change, not unless we want something comparable to or worse than our public education system.) I honestly feel like the subject of universal healthcare is one of the big reasons nothing happens, there are obvious negatives people can latch onto for counterpoints and prior attempts haven't been so great, so it's an option that is currently going to go nowhere. Instead we need to focus on the exploitative nature of healthcare and create an argument that is much harder for private healthcare to create opponents for. Private healthcare isn't necessarily a problem, and it has been a fairly decent system until the last decade or so, but once corruption took root it definitely became a big issue
@differnet You left out junk/fake food, alcohol, toxic chemicals, cigarettes, etc. Big pharma drugs kill over 100K a year, way more than guns do. The majority of gun deaths are suicides. Think they will shut down those anti-health industries and make life good for the peons so they don't kill themselves?!
The solution: preventative medicine. That means a healthy lifestyle, using healthy/organic food, non-toxic personal care and cleaning products, nontoxic furniture and building materials, pure air and water, and saying no to booze, big pharma and street drugs, and tobacco products. It means being outside and exercising, instead of being a "couch potato" addicted to tech, porn, shopping, eating, focusing on genitals, and all the other anti-life "vices" and past-times of modern society. Who wants to end all of that to have good health and save money?! Too much "fun" to be had being unhealthy, "since we only live once", right?! Prevention cuts sick care costs, but that does not make the corporate conies any money, is considered "boring", and people will live too long!
The rulers take advantage of people not knowing or caring about healing and staying healthy using "alternative therapies" and lifestyle choices, addressing the root causes of disease. Disease is NOT the result of a drug deficiency or lack of surgery! Why should we all pay for poor lifestyle choices, for someone that chooses be ill and not healthy?!
@@homerman76 - You seem to be arguing for the Swiss system. It's paid for by private insurance, the insurance companies are regulated in what they charge and what they must pay for.
The problem the US would have with it is that everyone is forced to buy it. All you need to do is take a look at how many drivers are uninsured in states that require insurance, and you know they won't be buying health insurance, either.
I’m waiting for the episode even 70% of the insurance company’s revenue comes from government funding to reduce health insurance cost
I have to get PAs for everything even with several allergies and multiple medication sensitivity on file. By default, I either pay out of pocket (-180, or 400 out of pocket every month while living at poverty level). My care is delayed by default.
I honestly think you can change something. Jimothy can change things.
Right on the money! Time to give health care back to doctors and patients! And put insurance executives in prison!
I have never in my life seen a more accurate video!
WOW! Concise, entertaining, and sad.
This is painfully true.
You should make a video of a US healthcare insurance employee needing a treatment or procedure and its prior authorization gets denied
I don’t miss working on the medical field. P.A. Is probably the one of the most soul ripping process I’ve seen
I work in billing followup for a multi hospital medical group. It saddens me and infuriates me that even when you have something authorized they can change their mind after they pay and forcefully take that money back years after the service. Thus leading to us having to fight tooth and nail to get paid again.
Can you guys, I don't know, class action them?
Really, it is just a guess. We need an Erin Brockovich of health insurance.
At this point, I feel like Jimothy is the one to blame because he's the one who keeps giving Medical Insurance all the crooked ideas.
Jimothy is definitely complicit
why *does* Jimothy work there? He's clearly not happy.
(I mean, the video series does raise perhaps more important questions about the health system, but I don't live in the US)
And this is why he gets paid the big dollars, not as much as his boss of course, but they figure his ideas are worth paying just enough to offset his moral compass
@@mattsword41 I worked for a health insurance company because they were the only ones who called me back. They take advantage of under-educated people to act as meat shields for their manager's paycheck.
Fun fact: In 2008, any company that had an HSA was one easily identified as a company that didn't give a shit about their employees at all. Now they're just normal and calculated on receipts?
@@mattsword41He doesn’t like what’s he is doing but they pay him plenty plus bonuses for his ideas.
What can we, normal nose down working people, do to change this healthcare system?
learn about alternative options, like socialized medicine. get vocal about it; drum up support from others. research political candidates at your local, state, and federal levels. and vote, vote, vote for candidates who are a step in the right direction. is the process slow? yes. but that is the process.
Vote for the people and political parties that are in favor of overhauling the system though things like medicaid expansion or medicaid for all
Write to government officials about it (governors, senate, congressmen) and agencies that are supposed to be overseeing and regulating this crapshow. Help a disabled person write THEIR complaints, as they've been deeper in the system than most anyone and abandoned by it and many are too burdened by poorly and untreated health problems to do so.
Sounds like a challenge, but there's this nifty little tool that's been pretty hot lately than can write things for you in whatever style you want that maaaaayyyy save a lot of time. What's it called...? ChateauGDP? Chat something something? 😉😏
Also, another comment suggested that once this series is complete, we all start emailing/tweeting/etc the playlist link to every Congressperson in the country at least once a month. Someone else suggested we include insurance company execs, and I suggested we aim for daily instead of monthly. There are more than enough of us to do it. I really think if a significant chunk of this fandom jumps on board and does even just a small bit of spamming it and we aim to make the flood last a few weeks, we'll be able to turn it into an internet phenomenon that gets media attention, which will be great for public awareness/education and also massively increase pressure on leadership. I seriously think it's a brilliant idea and we should do it. So here's hoping that takes off. It's one of the few things us people-at-the-bottom can do.
@@AliciaMcIntire Yeah which ones are those again? Bernie and the Bernie party?
I work as a financial counselor for a major hospital. Patients without insurance have to either prepay $300 for a specialist visit or procedure, or have to apply through us to find some other way to pay (like Medicaid, charity services, etc.) It causes no end of frustration when we have to call a patient and a facility the day of their appointment and tell them it's not approved and they have to cancel or pay because we didn't get the paperwork from the patient on time.
Oh, and I live in a state without expanded Medicaid, so good luck going that route if you're not disabled, a child or have children, or over 65. Thanks, General Assembly.
This is SO like a “ Pitch Meeting”!
Much as I LOVE your content, I equally HATE how spot on it is about how broken our healthcare system is in our nation. 😖😭💔
I hate how right you are. My life is now so painful and nonproductive filling out endless forms for PAs of things that I wouldn’t have ordered if they weren’t necessary. And don’t get me (or us) started on pharmaceutical middle management. 😡🤬
Every time the United Healthcare CEO smiles, all I see is Jonathan's evil twin 😂
Last week a dear friend’s life was put in the balance when her insurance company denied her a PACEMAKER!! Evil!!
I like how jimothy keeps getting aggravated with his boss every episode
I wonder what would happen if all the office workers at these health insurance companies walked out and quit!
Although many of them may actually be trying to help patients find ways to get authorization thru the labyrinth of bureaucracy.
Would be best for govt to just, you know, stop letting insurance providers practice medicine without a license!
I used to do all the PAs for the surgeon i worked with (am a PA). The cool thing is pretty much all the insurance Docs i talked with were understanding and approved everything. Never had to jump through hoops.
I believe your comment is accurate in most cases. It is not likely to be well received here.
But one could argue that 1) prior authorization is, in and of itself, a hoop and 2) the requirement to jump through it is, by definition, a delay in receiving care/treatment. Which they are. And it is utterly unjustifiable in cases of chronic conditions where an established and ongoing treatment has been in place for years (if not decades) yet still requires PA every few months throughout the year, every year.
@susanq8925 good point. I was in hand surgery and it was always acute issues and generally only happened when we got "exotic".
Just having to do frivolous PA’ s is jumping through hoops.
As a Dermatology Scribe, if a patient comes in with a rash we basically have to spin the roulette wheel for “which corticosteroid is covered by insurance”. Sometimes they come in for poison oak or similar and we want clobetasol or betamethasone (two of the strongest, class 1) and the insurance responds “have you tried hydrocortisone (Class 7, over the counter)? Lots of fun stuff.
The mail order or specialty brand names/ biologics I can understand but sometimes it’s a hassle just to prescribe doxycycline for a MRSA infection…
I was denied prior authorization for PT after my 6 week post partum checkup. I began doing PT in the 3rd trimester for pregnancy related pain affecting my mobility, & that prior authorization was approved. Then I had the baby, and was healing. But when I needed to resume PT after my 6 week post partum checkup, the order had expired, and for no reason whatsoever, my insurance denied the new prior authorization for the same location.
UHC insurance told PT that I hit my limit of PT visits for the year (36)… but I did not. I had 6 total with the last 2 not covered…
Then UHC told me that additional records were needed, and yet refused to clarify WHAT could possibly be needed as my midwives and PT said they sent medical records. So my midwives called to see what was still needed and this time UHC said that the PT was not in network & that I hit my limit of visits. (It is in network). I call UHC and was told again that my visit limit was hit, so I appealed with urgency because I cannot lift my baby well.
UHC calls back the next day to indicate that they will not actually review my appeal with urgency, rather in 3-4 weeks, and that they will use my midwive’s appeal in their system rather than mine because the medical records are attached to hers. I already had to cancel that week’s PT… I insist on urgency & that my statements be included in the appeal along with the medical records, as it was a false dilemma to feign as if they couldn’t be combined, and let them know I will be filing a BBB report if antics continue (as UHC likes to hang up on patients, feign confusion, talk through a tin can etc., anything to provoke you into giving up).
Suddenly within 24hrs I am approved to resume PT. 😑
Working in such an environment would drive me insane, more so than psychiatry already does
Insane is a bit extreme. Maybe unhinged is a good fit like you slowly turn into a robot incapable of feelings and the only thing that drives you is clocking out as soon as it hits 5 nothing more coz if you sold your soul might aswell not overwork.
Hahaha, love it when the medical team says that due to his latest test results my 4yo nephew now urgently needs a specific medication in order to live and the insurance company is like "but does he really?" and then takes a month to authorize the injections, and we spent that whole time fingers crossed that his condition wouldn't rapidly deteriorate before we could treat him.
I haven’t gotten my meds for 4 months now because of this
So prior authorisation does exist outside of the US, but it's super rare, even in the NHS.
What do you need prior authorisation for in the nhs?
@@whackeryounis High cost drugs such as Biologics that aren't exempt from special tariffs.
@@leo_warren ahh yea. I get that new high costing drugs, especially biologics need a cost:benefit analysis beforehand until the price goes down but thankfully super rare. Obv not ideal for the patient that isn’t sure if their treatment is covered especially when being used to not having to worry about such things for the vast majority of health issues. It does suck when a patient reaches the limit of what the nhs can offer but as you said, thankfully it’s rare
@@whackeryounis I've done it and it's taken me 4 years to get where I am. The biologics are far better and far more tolerable than the older drugs.
@@leo_warren biologics have been such a good break through for treatment. Sorry you had to wait so long for them to be preauthorised. I’m a med student so appreciate you informing me about the preauthorising. This stuff won’t get taught to us until we’re higher up the doctor chain. Hope the treatment is going on for you
your portrayal of health insurance reps both having 0 empathy and 0 medical knowledge is spot on. ever since i was little my mom and i have had many fun arguments with health insurance representatives over why i should get supplies for my t1 diabetes covered. one time i called them asking why my insulin prescription, you know, the thing my body doesnt make and i will literally die without, suddenly had a rather expensive copay, and i explained that im supposed to get it for free and always have, and this person, word for word, told me "why should you get it for free?" before i snapped back with "because i NEED IT TO LIVE", and then i had to switch to a different brand anyway that worked just different enough to where it impacted my blood sugars. on top of all that, when I was first diagnosed as a toddler, we couldnt even get insurance coverage for anything during the first year or so because of the "pre existing condition" crap at the time.
Prior authorizations wouldn't have to he a thing if hospitals didn't operate as profit centers. But since hospitals encourage (reward) doctors to run expensive and often unnecessary procedures and tests, this is what we get in response. So, yes, basically the insurance company is saying "prove you actually need this", because they know what is up. It's a two sided problem.
This series needs to turn into a legislative push for reform. Thank you for calling out the things that so many take as "normal"... it's not normal.
You see, here in the US, we're big on memes so it's very important to us that we maintain the 69th ranking in the world health index score.
Might as well go all the way to 420
@@jintsuubest9331 We would if there were enough countries. ¯\_(ツ)_/¯
I encourage all in this comments section to contact your representatives in congress and the president and forward this RUclips video to them. I was able to Google how to do it and post it to both my representative and the president while sitting on the porcelain throne. The internet makes this quick and easy to do.
My daughter went to the ED and had to stay overnight in the NICU. Insurance denied it because the doctor didn't get prior auth for the NICU admission.
Yes, of course. NICU patients are fine to wait for a day or two before being admitted... No problem. I hope they do the right thing and cover this for you.
🤦♀
Thats ridiculous. I hope your doctor was able to get that fixed. sorry you had to deal with that added stress.
During my career in medicine, I have seen doctors change from using their sound medical judgement when ordering tests and medications - to doctors using "shotgun medicine" - where they order virtually every test, all at the same time and prescribe medicines in the same way. It is a liability issue. The lawyers have corrupted the system just as much as the insurance companies have.
Thank you for making this series. 💙💙
That last line, like my insurance requires prior authorization for vitamins and I had severe deficiency, the prescription was less than $10 (still not something I can afford as I'm a college student) and the doctor's office told me they only do prior authorizations if the prescription is hundreds of dollars and there's no alternative
The current healthcare system in the United States is literally killing people to save pennies
In spring 2022 my son required gall bladder removal. He called me on a Friday said he was in awful pain…he was in this pain all weekend, Monday he saw a physician to schedule the surgery. That evening he died at home. I thought it should have been taken care of right away. I wonder if “prior authorization” was the culprit. It’s a sick, weird business health insurance. Why can’t we have healthcare like most modern countries?
Im sorry for your loss.
probably a combination of someone missing the urgency of the situation combined with insurance approval.
@@tammywilshire4170. Thank you.
@@tammywilshire4170 Thank you. Gallbladder trouble is in our family. I had mine out at 23 after my son was born. I was skinny as a rail. He was an adult. He called me about the pain, but said he’d see a doctor the next week. He had been diagnosed in an emergency room . It’s just so sad, 41 with a daughter to raise. I think they should have done the surgery as emergent. It’s done, he won’t come back. But this stuff with the insurance is just awful. Thank you for your condolences.
Here because I just got prior authorization'ed for the first time and I had to remind myself what that meant 🙃Thanks Jimothy!
You know how in Mortal Kombat if you pull off a sick combo the announcer chimes in: "impressive!"
Well what rang in my head was: "Depressing!"
Don't forget the company only approves a few treatments at a time, as if people may spontaneously recover from an expensive and chronic condition
That's not what that is. They only approve a few treatments at a time because the patient may have another insurance later. The prior authorization is stronger than insurance cancellation.
All the while creating a ton of extra work for doctors and pharmacists, which distracts us from being able to provide care to other patients, all without any sort of billable or reimbursable compensation. Larger institutions have to fund entire prior auth departments because of the amount of extra work this creates. It's lovely.
So, what if the insurance company additionally had to pay out in the case of their clients dying? Is this idea crazy? Already implemented somewhere? I feel like giving them an incentive to keep their patients alive would go a long way.
I feel like this series is just Jimothy's villain arc
These 30 days are going to be tough for Jimothy lol. That poor man.
I have a brain shunt for hydrocephalus, and every few years I need to go in for a CT scan. But first I need to wait for prior authorization to go through before I can get this necessary routine procedure to make sure something isn't wrong that could potentially kill me.
Gentle request for more dentist skits. You're hilarious Dr G!
Brilliant !! I hate insurance companies
If prior authorization almost pro forma you've got a problem. The point isn't to see if the patient needs it. The point is to look it up in the table and see if it's covered or not.
I wish I could like this video a million times! This is spot-on!
On the 5th day of September, Dr. Glaucomflecken taught,
Prior Auths practice med'cine with no license!!
Co-payments punish,
Co-insurance varies (but invariably sucks),
Deductibles are scams,
And how monthly premiums make us distraught
Currently paying 250/month for a specific medication out of pocket because my ins won't cover it without a prior authorization despite covering the immediate release version of it that would leave me unstable. Go insurance!
United Healthcare sent me a denial letter a few days ago denying a spinal procedure. The same procedure that was done two weeks ago after their initial approval. Their “in-house experts” reviewed the matter and determined I didn’t need it. So now prior authorizations mean nothing.
So much this. Prior auths have directly harmed my patients and are a key factor on doctor burnout