A physician’s fight against insurance denials [PODCAST]

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Join us in this compelling podcast episode as we dive into the world of insurance denials and the challenges faced by physicians and patients. Our guest, Jennifer Lycette, is not only a rural hematology-oncology physician but also a novelist and award-winning essayist. With her firsthand experience, she shares stories from the frontlines and sheds light on the impact of insurance denials on patient care. From the time constraints of appeal calls to the lack of understanding of individualized treatments, we explore the frustrations and consequences faced by both physicians and patients. Jennifer emphasizes the need for change, discussing the toll on physician burnout and the emotional and financial burdens on patients. We also delve into the importance of increased awareness, advocacy, and collaborative efforts to challenge insurance practices. Join us for an eye-opening conversation that delves into the human side of health care and the urgent need for reform.

Jennifer Lycette is a novelist, award-winning essayist, rural hematology-oncology physician, wife, and mom (to three humans and two of the canine persuasion). She can be reached on Twitter @JL_Lycette, Mastodon @[email protected], and LinkedIn. Her first novel, The Algorithm Will See You Now (Black Rose Writing Press), a near-future medical thriller, is out in paperback and ebook.

She shares her story and discusses her KevinMD article, “The insurance denial process: one oncologist’s fight against a broken system.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Jennifer Lycette. She is a novelist and a hematology-oncology physician. You can catch her novel, The Algorithm Will See You Now, wherever you buy books. Today we’re going to talk about her KevinMD article, “The insurance denial process: one oncologist’s fight against a broken system.” Jennifer, welcome back to the show.

Jennifer Lycette: Thank you for having me back. I’m happy to be here.

Kevin Pho: I think we last spoke over a year ago, and for those who didn’t get a chance to listen to our other episode together, just briefly share your story and journey to where you are today.

Jennifer Lycette: Well, sure. When we first met, it was in relation to an article I wrote after I had returned from actually leaving the practice of medicine for a year, and about my journey back from burnout. Writing has been a big part of that. My burnout actually happened right before the pandemic, and I came back in the first year of the pandemic, and I’ve been continuing to write. Thank you for allowing me to continue to reach people through your platform with my articles.

Kevin Pho: I think when we last spoke, you said that you were burnt out and left clinical medicine. So tell me your story since we last spoke.

Jennifer Lycette: Rural hematology-oncology. I practice in rural Oregon, and I do work part-time clinically, which, interestingly, I think is becoming more acceptable since the pandemic than it was before. So I am in clinic three days a week, and then I have my admin day, and then I try to write for a few days a week.

Kevin Pho: Describe your practice. What’s it like to practice hematology-oncology in a rural setting?

Jennifer Lycette: Oh, gosh. Actually, in relation to that question, first of all, I want to talk about the positives. I find it very rewarding because it allows me to be very close to patients, with fewer of the layers in between that happen in larger systems. Another thing about rural medicine is that we all wear a lot of different hats, because there are fewer of us: fewer doctors, fewer nurses, fewer staff. So the people who are drawn to it, and practice there, and stay are, I find, people who are very comfortable with switching hats and just being problem solvers. There’s really not a lot of “well, that’s not my job.” People just step up and do what needs to be done.

The challenges, I think, are the flip side of that. Even before the pandemic, rural areas struggled with recruiting and retention and understaffing, and of course none of that has gotten any better since the pandemic. That’s happening everywhere, of course, not just in rural areas. It is also a challenge, and I’m thinking of how to phrase this, that I meet so many people who come to care so late, and a lot of that is because of many socioeconomic barriers, financial barriers, and underinsurance. I think it all is a bit more magnified in the rural setting. We know that for cancer in particular, a lot of the environmental risk factors, like tobacco and obesity, are actually higher in rural areas, and that leads to increased cancer rates at younger ages. It’s all those layers, which I’m sure the listeners to your show are very familiar with. So it’s two sides of the coin, but I find that overall, what keeps me going is the ability to really focus on patient care, more so than I was able to do in a larger system.

Kevin Pho: What would be an example of something that you wouldn’t have in a rural hematology-oncology setting that someone may take for granted in a more resource-intensive setting?

Jennifer Lycette: Oh, goodness, I could list so many things. One thing is just the lack of other specialists. We have general surgery and myself and primary care, but we don’t have ENT, we don’t have pulmonary, we don’t have GI. Sometimes I talk to colleagues and they’re like, “How can you practice without all these people?”

But one of the things that has actually been so huge since the pandemic is the ability to do telemedicine. I was in rural medicine before the pandemic, and we talked about telehealth for years, but it never materialized. Unfortunately, it mainly seemed to come down to the issue that no one could figure out the billing and no one was motivated to do it. Then, with the pandemic, all of a sudden, of course, that got figured out very quickly. So my patients have actually really benefited, because now I can get them those virtual consults with those specialists so we can put together a multidisciplinary plan. So I’m actually really fearful of the new telemedicine rules that came about with the pandemic going away, because I think a lot of people don’t realize how that’s going to affect rural patients. So it’s been interesting how there have been some benefits of the pandemic with telehealth there.

Kevin Pho: All right, let’s talk about your KevinMD article, titled “The insurance denial process: one oncologist’s fight against a broken system.” So tell me, how did this article come together?

Jennifer Lycette: Yeah, absolutely. This article is actually a reflection on a big article in ProPublica in late March that was really an exposé on Cigna, and it’s so well done. If people haven’t read it, I highly recommend it. They essentially gathered evidence on Cigna. I would say I doubt it’s just Cigna, but Cigna was who they investigated. They found evidence that the so-called medical directors and nurse reviewers deny care without ever looking at the chart. They had some just appalling statistics, like a denial every 1.2 seconds. Then they looked at individual medical directors and found that in a month, they denied between 60,000 to 120,000 cases without ever opening the chart. It’s astounding.

I actually felt so vindicated when I read it, and I think so many physicians did, because I think that’s our clinical experience. We feel like we have to do these appeals and nobody has ever read the chart, but of course, we go through years of training to chart our rationale very carefully and thoughtfully, in the hopes that someone is reading it. So I wrote a reflection on that article. I wanted to let people know what it’s like for just a clinician in practice, how we do these appeals and how they take time away.

One of the other things that happened just near the time the article was published is that I went into a patient room after being delayed by having to do one of these appeals, and they said something like, “Oh, are you done with your lunch yet?” It was so disheartening. I think there’s this big disconnect between what a lot of laypeople think physicians do and what we’re actually having to do behind the scenes. So I tried to use the article to paint a portrait of what these denials are like, how we’re at the mercy of the insurance companies, how it takes us away from our other patients, and also the, I think, inexcusable mental and emotional strain it puts on the patients, too, especially in cancer care. So I wrote about a typical situation with a denial and appeal, and then also referenced the ProPublica article so people can hopefully read that as well.

Kevin Pho: Take us into your clinic. It could be this story, it could be another story, just to really paint a picture of what it’s really like to appeal a pre-authorization, a prior authorization, and then how that fits within your workflow.

Jennifer Lycette: Yeah. A typical process would be that I get a note from someone in our prior authorization department that says, “This was denied. Do you want to appeal?” I say yes, and then they contact the company to ask for an appeal, and then the appeal time and date is set without any regard to my schedule. Often it’s in the middle of a clinic day. They don’t do it after five. If you don’t agree to the time, they will close your appeal, and you have to start all over from the beginning. So even if I have patients waiting, and sometimes it’s instantaneous, like I talk about in the article, where I get a message like, “Oh, hey, we got you an appeal. It’s right now,” or, “It’s in 10 minutes,” it just is what it is.

The other frustration is that even though supposedly there’s a time set, you have to call the number, and then you typically have to go through a phone tree and talk to someone who’s not the person that can approve the appeal. So there’s a lot of hold time before you finally get to the person that you can talk to about the appeal, and I find that is usually 10 to 15 minutes long. Then, when I finally reach the physician, nine times out of ten they approve it within 30 seconds, because I tell them what’s going on. If they had read my note, they would have known that already, but of course they hadn’t read my note, and as we know from ProPublica, it’s a universal thing.

Kevin Pho: So what are some common things that you would have to appeal, that they’re denying?

Jennifer Lycette: Oh, my goodness, some days it seems like almost everything. Imaging: They want to micromanage imaging. They also are always behind on standards of care. So when there’s a new cancer drug approval with the FDA, I often have a patient immediately that I know would benefit from that, but it takes them months to update their guidelines, and it’s just rigid. If they can’t check the box, they won’t approve it. So you have to get on the phone and explain and provide the evidence, and then oftentimes they will still say, “Well, I don’t have a box to check.” So it’s extremely frustrating, the lag in their guidelines and this rigid, non-thinking approach that they have.

I think the great thing about ProPublica, not just with this article, is that they’ve actually done a whole series over these past few months about patients actually taking action and, in the process of legal discovery, actually getting recordings of the brutal, uncaring process of denials. One of the reasons I wrote my article is that I just think the more transparent we can all be, and the more we can get it in the public eye, hopefully we can see some change happen.

Kevin Pho: Now, eventually, when you get hold of the physician, what kind of doctor is that person? Are they trained in oncology and your specialty?

Jennifer Lycette: Yeah, sometimes, and those are the best. I always just breathe a sigh of relief when I find out it is another oncologist, because I know at least they have the training to understand my rationale. But probably at least 50 percent of the time, it’s not an oncologist, and it can even be a non-clinician, like a radiologist. Nothing against radiologists at all; I love radiologists. They help us do our job every day, but of course they aren’t trained in the nuances of chemotherapy, so it’s quite challenging sometimes.

Kevin Pho: How successful are you in general when it comes to appealing these denials?

Jennifer Lycette: Yeah, I’m actually very successful, because when I am appealing, it’s because I’m doing the right thing for my patient, and I have the expertise to know. I’m a board-certified hematologist and medical oncologist. I also have a sort of mantra for myself that I say: “I’m not hanging up until I get this approval.” I don’t think I’ve ever not succeeded in getting a treatment approved that I thought was the right treatment.

I would say the only thing I have not been successful on sometimes is PET scans. For some reason, insurance companies, I don’t know what they have against PET scans, to be honest. A lot of times we can get the same information from other scans, but we have to do two other scans to replace the PET scan, and that again is a hardship on the patient. I have had situations where they’ve just been inflexible, and because, thankfully, I can get what I need with two other scans, it’s unfortunately just a hardship for the patient. So I will say that’s the one thing I have occasionally not been successful on.

Kevin Pho: You mentioned earlier that patients, and the public in general, to be honest, really don’t know what you do in order to appeal these denials. So tell me, all these delays, all that time that you spend on the phone trying to convince someone who may or may not be an oncologist, how does that impact your patient care?

Jennifer Lycette: Yeah, I think it’s unfortunately the office delays. If I have a patient in a room and then I get the message like, “Hey, they say you have to do this appeal right now,” I’ve learned from experience that if we say no, then, like I said before, they actually close it out, and you have to start all over. So then, of course, I go see the next patient. Even though after a lot of years of doing this I think I have learned some more tools to re-center myself, and I think I’m pretty successful at that, at the same time I would still recognize the stress of that, and knowing that you’ve kept somebody else waiting, so you’re starting the visit where they’re frustrated. It all can kind of snowball.

Kevin Pho: Is the story the same among your other physician colleagues, locally in your clinic or that you converse with online?

Jennifer Lycette: I think so. There’s been a lot on social media. There’s a hashtag on Twitter, #FixPriorAuth, and a lot of physicians, not just oncologists, are sharing stories on there. Actually, physicians have turned to social media when there have been some very egregious denials, to put the pressure on the insurance company to overturn it. I haven’t yet had a case like that, thankfully, but I’ve certainly seen some on there with oncology. I think the other big one is the immunotherapy for inflammatory bowel disease. That’s been a big one, and that was one of the big stories in ProPublica as well. I’ve seen others on social media about that too.

Kevin Pho: Do you have any tips that you share with your fellow clinicians on how to manage the distress of the appeal process?

Jennifer Lycette: Oh, gosh. I would say I do try to be very friendly and upbeat when I talk to the person at the insurance company. I try to remember that they’re probably talking to angry physicians all day long. I will admit that in the beginning, and this is maybe 10 years ago, I had a few instances where I got pretty upset, and I found that escalating in that way doesn’t do anything. So again, I have this mantra in my mind: “Just be calm, be repetitive. I’m not hanging up until I get this approval.” Those are just kind of the things that go through my head.

I’ve also found that, again, even if we might not understand the job of someone doing these reviews, it helps to just try to recognize they are another physician and a colleague, and to start out the visit with a few friendly words. I think maybe they don’t get that very often, so it kind of puts them in a more receptive mindset. I realize as I say this that it sounds terrible that we have to think of these things, but it’s just become part of our lives now, part of our practice, these phone calls.

Kevin Pho: We’re talking to Jennifer Lycette. Like I said, she is a hematology-oncology physician, and she’s also an author. Her latest book is titled The Algorithm Will See You Now. We’re talking about prior authorization and appeals. Her KevinMD article is titled “The insurance denial process: one oncologist’s fight against a broken system.” Jennifer, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Jennifer Lycette: Let’s see. I think, again, my biggest take-home message is just about transparency and authenticity. I think sharing our experiences, whether it’s through writing an article or on social, just helps. The more we do it, the more people are going to understand what’s going on. I also think we need to be relentless. We need to stand up to these insurance companies and ask our medical societies and organizations to do the same thing.

Kevin Pho: Jennifer, thank you again for coming back on the show and sharing your time.

Jennifer Lycette: Thank you very much.

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