One weekend in late April, Leah Kovic was pulling invasive plants in the meadow near her home when a tick latched onto her leg.
He didn't notice the tiny insect until Monday, when he started feeling pain in his calf muscle. That same morning, she made a virtual appointment with a doctor recommended by her health plan, who prescribed a 10-day course of doxycycline to prevent Lyme disease and insisted that she also attend an in-person appointment. So later that day, she walked without an appointment to a clinic near her home in Brunswick, Maine, where she was examined and prescribed one, higher dose of the same medication.
This was the right decision, because during the visit, the clinic staff discovered another tick on Leah’s body. Additionally, after sending one of the bugs to a lab for testing, the test result came back positive for Lyme.
“I could have gotten really sick,” Kovic said.
But Kovich's insurance company refused to pay for the clinic visit. Cause? He did not receive a referral from his doctor to see a specialist or prior authorization. “Your plan does not cover this type of care, so we are denying this fee,” one document explains.
Health insurers have argued for years that prior authorization helps reduce fraud, unnecessary costs and protect patients. And while these denials are often associated with expensive treatments such as cancer treatments, the tiny tick bite Kovic suffered shows how companies also use these policies to avoid paying for all types of services, even those deemed economically and medically necessary.
Promises of change
Administration of President Donald Trump announced this summer that dozens of private health insurers have agreed to make significant changes to the prior authorization process.
The promise includes eliminating the authorization requirement for certain health care services entirely. It also decided to provide a grace period for patients who change medical plans so that they do not face new rules that interrupt their current treatment.
Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), announced at a press conference in June that some changes would take effect in January.
But so far, the federal government has not provided details about which diagnostic codes used for medical billing purposes will be exempt from prior authorization or how it will force private insurers to comply with the new rules. It's unclear whether cases like Kovic's, which involves Lyme disease, will be exempt.
Chris Bond, a spokesman for AHIP, the health insurance industry's main trade group, confirmed that insurers have committed to implementing some changes by Jan. 1. Other changes They will take longer. For example, companies have agreed to respond to 80% of authorization requests in “real time,” but this will not happen until 2027.
Andrew Nixon, a spokesman for the U.S. Department of Health and Human Services (HHS), explained to KFF Health News that the changes promised by insurers are aimed at “reducing bureaucracy, speeding up health care decision-making and encouraging transparency,” although he cautioned that the full effect will take time.
Meanwhile, some health policy experts are skeptical about whether the companies will actually deliver on their promises. This is not the first time major insurers have announced reforms to the pre-authorization process.
Bobby MukkamalaPresident of the American Medical Association (AMA), wrote in July that promises made by insurers in June are “almost identical” to those made by the insurance industry in 2018.
“I think it's a scam,” said Neil Shah, the book's author. Insured by Edith: how health insurance is deceiving Americans – and how we will get it back (“Insured to Death: How Health Insurance is Harming Americans and How We Can Bring It Back”).
According to Shah, the insurers signed the agreement under public pressure. The collective outrage against insurance companies has intensified since the death of United Healthcare CEO Brian Thompson in December. Oz noted that the insurers' decision was a response to “violence on the streets.”
“More and more claims are being rejected,” said Shah, one of the founders Counter healtha company that uses artificial intelligence to help patients appeal insurance denials. “Nobody takes responsibility.”
Solve the matter
Kovic's bill for the clinic was $238, which she had to pay out of pocket after learning her insurance company, Anthem, wouldn't cover a dime. He first tried to appeal the decision. She even received a retroactive referral from her primary care physician confirming the need for the visit.
It didn't work. Anthem again denied its coverage of the events. Kovic said that when she called to find out the reason, the representative she spoke with was unable to explain.
“They didn’t seem to understand it,” Kovic explained. “All they said over and over again was that I didn't have prior permission.”
Jim Turner, a spokesman for Anthem, later attributed the insurer's denial to a “billing error” made by Maine Health, the health system that operates the clinic where Kovic was treated. Because of the error, the claim was processed as if it were a specialist visit rather than a doctor's visit or urgent care, Turner said.
Turner did not provide documentation showing how the error occurred. Medical records provided by Kovic show that Maine Health coded his visit as “tick bite to left calf, first contact,” and it is unclear why Anthem interpreted this as a visit to a specialist.
After KFF Health News contacted Anthem to inquire about Kovic's bill, Turner said the company “should have identified the billing error earlier in the process and we apologize for the inconvenience this caused Ms. Kovic.”
Maine Health spokeswoman Caroline Cornish said this is not the first time Anthem has denied coverage to patients who show up for appointments. He noted that Anthem's processing rules are sometimes incorrectly applied to these types of visits, resulting in “unreasonable denials.”
He said those visits should not require prior authorization and that Kovic's case illustrates how insurers often use administrative denials as an initial response.
“Maine Health believes insurers should focus on paying for the care their members need, rather than creating barriers that delay coverage and may discourage patients from seeking care,” he said. “The system is too often rigged against the people it is supposed to serve,” he added.
Finally, in October, Anthem sent Kovic an update on its benefits, saying a combination of premiums and discounts would cover the full cost of the visit. Kovic said a company representative called her to apologize. In early November, he received a refund of $238.
But she recently learned that under new rules set by Anthem, her annual eye appointment now requires a referral from her primary care physician.
“It remains the same,” he said. “But now I know better how they work.”
