As public scrutiny of the health insurance industry continues to mount, another group has emerged among those who claim they have been harmed by insurance company practices.
Cancer patients, their families and physicians said insurance is often the barrier that stands in the way of lifesaving care, according to a Dec. 27 NBC News investigation.
Here are five notes from the report:
- Insurers employ a peer-review process to determine whether certain treatments, screening tests or procedures should be covered by the company. The prescribing physician is required to discuss a patient's case with another physician, paid by the insurance company. The insurance company's physician will then decide if the treatment, test or procedure is medically necessary.
The NBC News report said health insurance companies claim this practice saves money, while physicians said the practice inhibits patient care. The peer-review process often enlists a physician who is not a specialist in the proposed treatment or area of care. Additionally, insurers do not publish their rules for treatment approvals or identify approved alternative treatment options, requiring physicians to continually submit claims that may never be approved, the report said. - Claim denials and appeal processes take time, which many cancer patients do not have. NBC News cited two recent studies highlighting the disproportionate harm cancer patients experience because of care denials and delays.
A 2022 American Society of Clinical Oncology survey found that 42% of cancer patient prior authorizations were delayed by more than one business day, with 14% of those delays resulting in a serious adverse event such as delay or denial of treatment, disease progression or death.
A 2023 JAMA Network study found that 22% of cancer patients did not receive physician recommended care because of authorization delays or denials. - Bruce Scott, MD, president of the American Medical Association, told NBC News the organization met with health insurance companies five years ago to discuss preauthorization practices.
"We walked out of the room with what we thought was an agreement. But since then, there's been no action," Dr. Scott said. "Since that togetherness we had with them, things have gotten worse." - Texas — home to the largest cancer center in the world, Houston-based University of Texas MD Anderson Cancer Center — has implemented statewide solutions to preauthorization issues.
In 2021, Texas passed the Gold Card Act, which allows eligible physicians to be exempt from the insurance authorization process. In 2023, the state passed legislation allowing autoimmune disease patients to be exempt from prior authorization practices.
Ezequiel Silva, MD, an interventional radiologist and chair of the Texas Medical Association Council on Legislation, told NBC News cancer patients should be eligible to receive exemptions from prior authorization as well.
"Nowhere are the stakes higher than in cancer care, where delays can literally be the difference between life and death," Dr. Scott told NBC News. - The NBC News investigation also found an alarming increase in the number of Medicare reimbursement denials for ultrasound breast cancer screenings from 2023 to 2024, citing physician records and corroboration.
When presented with the information, a CMS spokesperson told NBC News that ultrasounds or MRI scans are covered by Medicare as diagnostic tests, not screening tests. Madhavi Raghu, MD, a radiation oncologist based in Connecticut, told the news outlet that breast ultrasounds have only one Medicare reimbursement code which does not differentiate between diagnostic or screening tests.
The FDA recently passed a rule requiring healthcare facilities that provide breast imaging services to notify patients of their breast density in mammography reports. Having dense breasts means a patient may be a good candidate for additional cancer screening, though the FDA's regulation does not standardize how physicians should proceed after a patient is identified as having dense breasts nor does it impose any requirements on insurance companies to cover additional screening.
"It's unfair to tell a patient you have an increased risk of developing cancer and we have another test to find it, but [the patient is] going to have to pay for that," Dr. Raghu told NBC News. "It upsets me to see patients who come in with stage 3 breast cancers because they didn't have the opportunity to get screening beforehand."
Read the full NBC News report, including firsthand accounts from cancer patients, their families and physicians, here.