Sick Patients Battle Insurance Denials Despite Policy Changes
By Lauren Sausser | KFF Health News
March 31, 2025, 1:19 PM
In the ongoing struggle faced by patients with complex medical conditions, many are met with a frustrating barrier: insurance denials. Despite recent attempts to reform prior authorization practices, individuals like 30-year-old Sheldon Ekirch continue to find themselves waiting on the phone, advocating for necessary treatments that their health insurance providers refuse to cover.
A Continuous Fight for Care
Sheldon Ekirch, a Henrico, Virginia resident, suffers from small fiber neuropathy, a disorder characterized by near-constant pain. Following her diagnosis in 2023, she has been reliant on over a dozen medications to manage chronic pain and insomnia. Though Ekirch has been advised by specialists to undergo intravenous immunoglobulin (IVIG) treatments that might alleviate her suffering, her insurance company has denied coverage repeatedly.
“I’m paying a lot of money for health insurance… I don’t understand why they won’t help me," expressed Ekirch, frustrated at the implications of her coverage denial, which could amount to over $100,000 for the IVIG treatment.
This experience is emblematic of a broader systemic issue where prior authorization—a process requiring approval from insurance companies before patients can receive certain treatments—has forced many into prolonged waits and uncertainty about care.
Understanding the Prior Authorization Process
For nearly 50 years, health insurers have utilized prior authorization as a mechanism to control spending and prevent unnecessary medical procedures. However, the rules associated with this practice vary widely among different insurance plans, which often creates confusion among patients and healthcare providers alike.
Reports indicate that the process disproportionately affects patients who require the most intensive care. According to Justin Lo, a senior researcher at KFF Health News, there is a significant lack of transparency regarding the frequency of prior authorization requests and denials.
While bipartisan efforts have been made to address these issues, skepticism remains about the extent of these reforms’ effectiveness. Judson Ivy, a revenue cycle management expert, described some insurer initiatives as mere public relations efforts failing to address core issues.
Personal Stories Highlight System Flaws
Arman Shahriar, an internal medicine resident, faced his own challenges when his father’s insurance denied a critical whole-body PET scan for his father, who was diagnosed with follicular lymphoma. Shahriar spent significant time navigating the bureaucratic hurdles of prior authorization, ultimately securing approval but experiencing delays that left his family anxious about his father’s health.
“The confusing system is artificially creating problems at the wrong time,” Shahriar argued, emphasizing that if families with medical backgrounds are struggling, others without that knowledge face an even more daunting task.
Calls for Reform Amidst Public Outcry
The tragic loss of UnitedHealthcare CEO Brian Thompson in December 2024 sparked outrage regarding insurance practices, prompting discussions about reforms in the industry. A poll by Emerson College revealed that many young adults expressed understanding of violence arising from frustrations with insurance companies, reflecting a broader public sentiment against the issues within healthcare.
In response, Cigna Group CEO David Cordani acknowledged that the incidents have prompted the company to “listen more intensely” to public concern about prior authorizations. Government initiatives have also emerged, with both the Trump and Biden administrations pushing for improved transparency in prior authorization processes, such as mandating electronic systems and streamlined decision times. Yet, these changes alone may not sufficiently protect vulnerable patients.
Legislative Efforts and Future Prospects
Several states have enacted laws aimed at regulating the prior authorization process, mandating insurers to disclose denial data and establishing “gold card” systems that allow experienced physicians to bypass authorization for certain procedures. Virginia recently approved legislation to enhance these efforts, set to take effect in July.
Yet doubts linger regarding whether these legislative changes will genuinely alleviate the burdens on patients or merely shift the difficulties elsewhere. Kindyl Boyer of the Infusion Access Foundation described the situation as akin to playing "Whac-A-Mole," suggesting that insurance companies may find new ways to restrict access to necessary treatments.
As the healthcare landscape continues to evolve, the collective frustrations of patients and advocates alike highlight the urgent need for comprehensive reforms that ensure access to timely and necessary medical care without navigating the obstacles posed by insurance companies.
The journey for patients like Ekirch and Shahriar illuminates the undeniable challenges within a system that often prioritizes corporate profits over patient welfare. With efforts underway at local and national levels, many hope for a future where patients receive the care they need without the burdens of prior authorization hindering their health outcomes.
