Are you a physician frustrated with the administrative headaches and their impact on your patients?
Have you ever faced denials for a care plan within standard practice for a patient?
Please tell the NCMS how prior authorization has impacted you and your patients.
We are looking for stories from physicians to highlight and draw attention to this issue that is impacting the health of so many North Carolinians.
Click here to tell the NCMS more!
Hi,
I am glad the NCMS is working on prior authorization reform. This is a big headache for us. We see a lot of times a patient is doing well on a medication and then suddenly, for no apparent reason, it is no longer covered and we have to go through a series of hoops to get the patient back on their medication. Other times, when we order meds, we don’t know if it is covered by their insurance or not. I think more transparency is needed. The medications should be definitely flagged if not covered, and also which alternatives are covered because it is very difficult to find this information-we don’t have time to be calling insurances to see what is covered. Occasionally the information is provided, but not regularly. Another possibility would be to provide all the information on the cost of the medications out of pocket to the patient in the electronic medical record so we could help them make an informed decision
Also, I have a suggestion for medicaid prescription covered list. It is very cumbersome to go through from top to bottom looking for a specific medication to see if it is covered. I think they could figure out a way to plug in the medication you are looking for (or type of medication) and it would take you directly to that section in the list.
Thank you for your time!
I have a patient who is a young man with multiple sclerosis. His brain MRI showed an extensive amount of disease, necessitating a highly effective MS medicine. He was stabilized on a strong MS medicine called Kesimpta. About a year into his treatment, he had to change insurance, and his new insurance required him to try and fail 4 different MS medicines before they would allow him to continue on the MS medicine he had been taking. After multiple appeals, he ended up getting free drug from the company that makes Kesimpta.
I have a patient with neuromyelitis optica spectrum disorder (NMOSD), a debilitating neuro-immunologic condition that can result in blindness, numbness, weakness, and difficulty walking. Her first relapse consisted of double vision, nausea, vomiting, and hiccups, and led to her diagnosis. She recovered and we tried to get her on a strong NMOSD medication called Soliris. At that time, Soliris was one of the only FDA-approved medications for her condition, but her insurance company would not cover it. They recommended she try an older immunosuppressive medicine that was not FDA-approved for her condition. During a peer to peer, I was told that she could qualify for Soliris if she had a second relapse. Unfortunately, shortly after that peer to peer, she had her second relapse. That one was much more severe, resulting in paralysis of her arms and legs. She was hospitalized for weeks, then went to rehab for several more weeks, and had to take many months off work. She was approved for Soliris after her second relapse and has done remarkably well, with no relapses in almost 5 years despite having 2 relapses within the first 6 months. If she had been able to start Soliris earlier, I believe she would not have had that disabling relapse.
I have a patient story that needs to be shared loud and clear.
Patient: Cliff Dilts
Spouse (now widow): Terri Dilts
phone number: 910-984-7282
I spoke with Terri today and she is happy to share her husbands prior auth nightmare with anyone who will listen, including the state legislators.
Here is a brief summary:
Cliff worked in HVAC. He presented to the EmergeOrtho urgent care with shoulder pain in July 2024. After failing some conservative treatment options, and having some benign appearing x rays, we ordered an MRI of his Left shoulder. MRI was performed on 8/21/24- per the report:
1. There is prominent bone marrow signal alteration throughout the entirety of the glenoid and extending into the more medial aspect of the scapula with
periscapular edema and mild muscular edema within the adjacent periscapular muscles. There is a linear component (or components) of the signal alteration within the glenoid/scapula concerning for a nondisplaced fracture, although an ill-defined intraosseous mass within the glenoid/scapula cannot be excluded, and a CT of the scapula is strongly suggested for further
evaluation/characterization.
I personally reviewed these MRI images and agreed with the Radiologist- a CT was recommended and ordered to assess this atypical marrow signal and possible associated fracture.
The CT was subsequently denied by BCBS of NC- 4 separate times. Each time the CT was denied, we submitted the “missing” information requested, and a new reason for denial was generated by Carelon Medical Benefits Mgmt INC on behalf of BCBS. Upon the 4th denial, Carelon indicated we had “exhausted” our appeal process and the case was closed with the “adverse determination upheld”.
Meanwhile our patient, Cliff, continued to worsen. Cliff and Terri tried to pay for a CT scan out of pocket, but couldn’t. Without any additional option, we ultimately directed him to go to the ER for a CT scan.
The ER provider contacted me directly and we discussed his case. The CT was done in the ER to circumvent the prior authorization process. As anticipated, the CT of his shoulder demonstrated:
” a large destructive lesion of the left scapula with a imposed pathologic fracture through the glenoid and coracoid. additional lytic lesions in the left 5th rib and multiple vertebre consistent with metastatic disease.”
While in the ER we continued his workup with additional CT of the Chest, abdomen and pelvis to assist in identification of the primary cancer.
Cliff’s diagnosis of metastatic cancer was significantly delayed by the harmful and unnecessary BCBS prior authorization process.
He was referred to oncology and initiated treatment. However he passed away in Feb 2025.
His spouse, Terri, informed me that she had contacted 5 different attorney’s to review the case, but no one want’s to take on a lawsuit against “big blue”.
Please let me know if I can assist in any way in bringing attention to this issue.
Thanks!
Lucas Romine MD
EmergeOrtho
919-717-3122