Takeaway
Patients are often faced with automatic denials from insurance companies. When advocating for patients, healthcare professionals can stay calm, present facts clearly, and prioritize the patient’s best interests.
Passion in the Medical Profession | July 10, 2025 | 2 min read
By Eric Last, DO, Northwell Health
In clinical medicine, we’re challenged daily by insurance companies denying care. It seems that the default setting is to deny requests for medical procedures, medications, and diagnostic testing. Once that default is toggled on, those of us advocating for appropriate care for patients have two options: engage in the cumbersome process of appealing the negative determination or acquiesce and find an alternate treatment or test for the patient.
We’ve all experienced this awful process, either as practitioners or as patients. The frustration doesn’t just end with the “negative determination.” The next procedural step is that maddening “appeal.”
Recently, my request for prior authorization for a CT scan to further evaluate a possible adrenal mass seen on a sonogram was the victim of the “default no.” My staff was told the denial was because I hadn’t noted the size of the abnormality seen on the sonogram in my initial request. I chose to appeal the decision. When the reviewer joined me on the appeal call, she asked me to tell her the story behind my request, “Because I didn’t have a chance to review the supporting documentation.” She told me that there was in fact no indication of why the request was denied, only that it had been denied (back to the default “no”). My reaction was a mixture of anger, frustration, and resentment. But, at the end of the call, the patient got the care she needed (and the Hounsfield quantification I needed to guide her management). I got to take an extra dose of antacid.
How best to deal with the conflicting defaults of denial of care on the one hand, and our dictum to always advocate for our patients? A few suggestions I’ve found helpful:
1. Always put the patient’s best interests first.
2. Have your facts ready.
3. Remind yourself that the person with whom you’re speaking is doing a job, even though their mission may seem anathema to your own.
4. Have a Plan B. I’ve fallen back on, “Well, Dr. So-and-So, if my patient can’t have that test, what do you suggest?” I sweeten this challenge by letting the reviewer know, sincerely, that I’d be happy to learn of a better, perhaps more appropriate way to help my patients.
5. Acknowledge that these interactions anger you and try to take that meditative deep breath (or whatever you find helpful) before you react to whatever is said.
6. Circle back to the first suggestion and remind the reviewer that your only concern is the welfare and best interests of your patients.
Our wish would be that imaging and procedural prior authorizations and pharmacy benefit managers be relegated to passe medical history. The reality is that, for now, they’re with us, as tools of the insurance/medical complex. And so, dealing with them is another one of the multitudes of difficult realities of modern medical care with which we need to cope—while trying to fight them whenever we can.
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This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.