Detroit-based oncologist Clara Hwang, MD, could not believe what she was seeing.
“We are unable to approve your request for this drug,” read a letter from WellCare, a Medicare Advantage plan.
Hwang had just prescribed darolutamide (Nubeqa) to her patient. The oral agent had received FDA approval a month prior, in August 2022, for patients just like this one — men with metastatic hormone-sensitive prostate cancer on a gonadotropin-releasing hormone (GnRH) analog or who had a bilateral orchiectomy.
“I prescribed within the indication,” Hwang, a medical oncologist with Henry Ford Health specializing in genitourinary cancers, told Medscape Medical News. “The denial I got was infuriating.”
The letter, which Hwang posted to Twitter, indicated that the prescription had been denied because the requested agent had to be provided in combination with a GnRH analog or after bilateral orchiectomy but, according to WellCare, the “records your doctor gave us did not show you met (any of) the requirements.”
Hwang was confused.
When Hwang reviewed the prior authorization request, she saw her team had indicated the patient was receiving a GnRH analog. In fact, the request included all information needed to get the prescription approved.
Her team called WellCare to point out the error.
“The only possible conclusion was that the insurance company did not read the submitted information carefully enough, or were not able to interpret it correctly,” Hwang said.
Medscape Medical News reached out to WellCare to find out why the initial denial happened and how they plan to prevent potential denial errors in the future. A WellCare spokesperson responded that the company “cannot comment on individual care plans due to privacy laws” but said that when members or clinicians have concerns, “we have policies and procedures in place to actively address those concerns and resolve the issue as quickly as possible.”
Following a prior authorization denial, physicians typically cannot simply resubmit the request, even if it was a company error. When Hwang tweeted about the error on September 30, she received a response from WellCare asking her to “please follow the appeals process on the denial letter.”
Before Hwang could send the appeals letter, she discovered WellCare had reopened the case and started the review process again.
Even though Hwang had bypassed the appeals process, it took over a week for the drug to be approved. The entire process took a few weeks, she said.
In the end, Hwang was relieved to secure the drug for her patient but wishes she and her team were not forced to go through such time-consuming steps to do so.
“This was one of the more frustrating prior authorization scenarios I’ve encountered,” Hwang said.
Revamp on the Horizon?
In Michigan, 94% of physicians report that prior authorization red tape causes delays in care for their patients.
The denial Hwang encountered suggests that “the staff making these decisions do not have enough medical knowledge to make good decisions,” she said.
A 2018 report from the Office of the Inspector General raised concerns about the prior authorization process: 75% of appeals following prior authorization denials in Medicare Advantage were overturned, suggesting that these plans are likely denying services that should have been approved when requested.
Potential fixes are on the way.
In April 2022, Michigan Gov. Gretchen Whitmer signed prior authorization reform into law, with the aim of reducing wait times as well as the time physician teams spend on this process. By June, the law will require insurers to make a standardized electronic prior authorization request transaction process available. And for urgent requests, the law says that the prior authorization is considered granted if the insurer fails to act within 72 hours of the submission.
This is part of our Gatekeepers of Care series on issues oncologists and people with cancer face navigating health insurance company requirements. Read more about the series here .
Please email firstname.lastname@example.org to share experiences with prior authorization or other challenges receiving care.