A rant about Medicare Advantage and pre-authorization.

No sooner had I hit the publish button on yesterday’s post about New York municipal employee’s battle with Mayor Adams and UFT President Michael Mulgrew over the city’s attempt to shift them to a privatized Aetna Medicare Advantage program then I received a letter from my own state teacher retired Aetna MA insurance program approving my doctor-ordered MRI.

The thing is that I am scheduled for the MRI tomorrow. It’s part of a two-year follow up to my kidney cancer surgery. It’s being done to see if there is a recurrence of any cancer.

It’s kind of important to me and a standard procedure for those who have had cancer.

But Aetna gets to approve it or deny it, second guessing best practices and the doctor’s request.

What if they had denied coverage?

I could appeal it and likely get approval after my doctor intervened. But it would have delayed the MRI for maybe months.

Since the state of Illinois switched from United Healthcare to Aetna in January I have needed pre-authorization four times.

Four times in seven months some private insurance bureaucrat had the nearly final say over what my medical professionals had prescribed.

Look. I’m 75. Body parts don’t always work the way they did when I was 25.

For an enlarged prostate my urologist prescribed a drug that is normally used for erectile disfunction. Aetna denied authorization. They explained that for erectile disfunction Medicare only approved five doses a month.

“I don’t have erectile disfunction,” I explained. “But if I did are you saying Medicare and Medicare Advantage say that those over 65 can only have penetrative sex five times a month?”

Pre-authorization is just one of the things wrong with the privatization of healthcare in the United States.

As a friend commented on my latest battle with MA pre-authorization, it is easier to get a gun in America than it is to get healthcare.

Some friends have told me to switch MA programs.

But Aetna is the only program provided to Illinois teacher retirees that gets a subsidy.

Besides nearly 99% Medicare Advantage plans require some form of pre-authorization.

Forbes reported that an American Medical Rehabilitation Providers Association (AMRPA) survey of rehab hospitals and units found that MA plans overrule rehabilitation physician judgment 53% of the time.

The AMRPA report called pre-authorizations “a widespread and common problem that can harm patients.”

In 2021, 2 million MA prior authorization determinations were denied, according to a February 2023 Kaiser Family Foundation (KFF) analysis.

That’s 6% of the 35 million requests. 

David Lipschutz, associate director of the Center for Medicare Advocacy, calls prior authorization “endemic.”

Denials by MA plans for authorization occur because some plans have been hiring subcontractors and using algorithms to make these decisions.

An algorithm is over-ruling a medical professional.

In a 2022 American Medical Association survey, 94% of the 1,001 doctors polled said pre-authorization delayed medical care. Roughly a third said it led to a serious adverse event for a patient.

In August I have another procedure requiring pre-authorization. When I called Northwestern Memorial to find out when they would send out the authorization to Aetna I was told they would send it out about a week before the doctor-prescribed medical procedure is scheduled even though the procedure has been scheduled for six months.

But if they deny authorization?

“Then we will appeal it and probably get the approval,” the voice on the other end told me.

“But it will take months to reschedule,” I explained.

“Probably,” he said.