Mr. Sullivan had been experiencing involuntary hand tremors, muscle weakness and cramping, tripping and balance problems, and occasional slurring of his speech. He thought these symptoms were the result of overwork and fatigue. But rather than improving over time, his symptoms worsened in intensity and became more frequent. He and his wife were increasingly alarmed about what these symptoms could mean for his health. He consulted his primary care physician (PCP) who performed routine lab work and found no definitive answers. Given Mr. Sullivan’s symptoms, his primary care doctor referred him to a neurologist in his MA plan network. Several weeks later, the day prior to his appointment, the neurologist’s office called Mr. Sullivan to say they would have to postpone his appointment, as they had not yet received prior authorization from his MA plan for the appointment.
After three more weeks, Mr. Sullivan finally saw the neurologist who then said he would order a battery of tests to better understand what was causing his symptoms. The neurologist said when the tests were scheduled he would let Mr. Sullivan know. After a week, the neurologist’s office told Mr. Sullivan that the doctor had not been able to get through to the MA plan to obtain the approval to schedule the testing. Several calls later, this was resolved and the tests were scheduled, except the MA plan did not approve a CT scan the doctor had ordered. The MA plan said they wanted to see the results of the other testing first.
Based on test results (including a delayed CT scan), Mr. Sullivan’s increasing symptoms, and the neurologist’s own expertise, the neurologist told Mr. Sullivan he likely had Lou Gehrig’s Disease (ALS), but the neurologist was not a specialist in ALS, and he did not feel qualified to give Mr. Sullivan a definitive diagnosis. No other neurologist in his MA plan network was a specialist in ALS. Mr. Sullivan requested the MA plan pay for the opinion of such a specialist. The MA plan denied his request as they did not consider it to be reasonable or necessary. The Center for Medicare Advocacy intervened with the MA plan on his behalf, as did the neurologist who had seen Mr. Sullivan, and another neurologist who was a specialist in ALS. After another week of consideration, the MA plan excepted the argument that the network was not adequate to meet Mr. Sullivan’s medical needs and agreed to cover him to go out of network to see a neurologist who specialized in ALS.
If Mr. Sullivan had been in traditional Medicare, he would have been able to see any Medicare participating specialists and have the tests that those specialists deemed reasonable and necessary. This would likely have been much more expedient, based on the recommendations of physicians who were actually examining and treating him, and Medicare would cover the care.
The unfortunate truth is that prior authorization means that MA plans use their own in-house doctors and medical case “utilization” reviewers who may delay or override the decision of a patient’s treating doctors. Although MA plan in-house doctors have never treated or examined Mr. Sullivan, they may ultimately make a decision that delays or denies necessary care.
Mr. Sullivan, his wife, and his family needlessly spent weeks of sleepless nights, waiting and fighting for his right to learn his true diagnosis. They also lost precious weeks moving forward to plan and prepare for their future, given his ultimate diagnosis.
Prior authorization is often touted as a screening tool to “manage care.” Too often, however, it is used as a prior delay or denial tool by MA plans.
The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars to promote informed choice by beneficiaries. As the Center has written, information about Medicare coverage options produced by the Medicare agency is no longer neutral; instead it now actively promotes private Medicare Advantage (MA) enrollment, and paints MA plans in the most favorable light, while downplaying their drawbacks. We have heard from a number of beneficiaries, advocates, and providers about their MA experiences. This is the third in a series to highlight these first-hand reports, and to counter-balance MA industry advertising and Medicare agency’s steering beneficiaries into MA. In today’s CMA Alert, and upcoming Alerts, we will write about other beneficiary, advocate, and provider experiences. These are all cautionary tales about Medicare Advantage that are not receiving adequate attention elsewhere.
We invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.
December 5, 2019 – K. Holt
 Factual recount as reported to CMA. The names of the beneficiaries, provider, and MA plans have been withheld for privacy purposes.