A weekend in late April, Leah Kovitch was pulling up invasive plants in a meadow near her home when a tick latched onto her leg.
She didn’t notice the tiny insect until Monday, when she started feeling pain in her calf muscle. That same morning, she had a virtual appointment with a doctor — recommended by her health plan — who prescribed a 10-day course of doxycycline to prevent Lyme disease and urged her to also get an in-person evaluation. So, later that day, she went, without an appointment, to a clinic near her home in Brunswick, Maine, where she was assessed and prescribed a higher, single dose of the same medication.
It was a good decision because the clinic staff found another tick on Leah’s body during that visit. Furthermore, after sending one of the insects to a lab for analysis, the test result came back positive for Lyme.
“I could have gotten seriously ill,” said Kovitch.
But Kovitch’s insurer rejected covering the clinic visit. The reason? She hadn’t obtained a referral from her doctor to see a specialist or prior authorization. “Your plan does not cover this type of care, therefore, we deny this charge,” a document explained.
Health insurers have argued for years that prior authorization helps reduce fraud, unnecessary expenses, and protects patients. And while these rejections are often associated with costly treatments like cancer, the tiny tick bite that Kovitch experienced shows how companies also use this policy to avoid paying for services of all kinds, even when they are deemed cost-effective and medically necessary.
### Promises of Change
The Trump administration announced this summer that dozens of private health insurers agreed to make significant changes to the prior authorization process.
The promise includes completely eliminating the authorization requirement for certain medical services. It was also agreed to grant a grace period for patients switching health plans, so they don’t face new rules that disrupt their ongoing treatments.
Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), announced in a press conference in June that some of the changes would take effect in January.
However, so far, the federal government has offered few details on which diagnostic codes — used for medical billing purposes — will be exempt from prior authorization, or how it will ensure that private insurers comply with the new rules. It is unclear if cases like Kovitch’s, related to Lyme disease, would be exempt.
Chris Bond, a spokesperson for AHIP, the leading trade group for the health insurance industry, confirmed that insurers committed to implementing some of the changes by January 1st. Other changes will take longer. For example, companies agreed to respond to 80% of authorization requests in “real-time,” but that won’t happen until 2027.
Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services (HHS), explained to KFF Health News that the promised changes by insurers aim to “reduce bureaucracy, expedite healthcare decisions, and promote transparency,” although he cautioned that it will take time to fully impact.
Meanwhile, some health policy experts are skeptical about whether companies will actually deliver on their promises. This is not the first time that major insurers have announced a reform of the prior authorization process.
### Resolving the Case
The bill Kovitch received for her clinic visit was $238, and she had to pay it out of pocket after learning that her insurer, Anthem, would not cover a single cent. She first tried to appeal the decision. She even obtained a retroactive referral from her primary care doctor, endorsing the need for the visit.
It didn’t work. Anthem denied coverage again. Kovitch said that when she called to inquire about the reason, the representative she spoke with couldn’t explain.
“It was like they didn’t understand,” Kovitch explained. “All they kept repeating, over and over, was that I didn’t have prior authorization.”
Later, Jim Turner, a spokesperson for Anthem, attributed the insurer’s rejection to a “billing error” made by Maine Health, the healthcare system that operates the clinic where Kovitch was treated. According to Turner, the error caused the claim to be processed as if it were a specialist visit, rather than a walk-in or urgent care visit.
Turner did not provide documentation showing how the error occurred. The medical records Kovitch provided showed that Maine Health coded her visit as “tick bite on the lower left leg, initial encounter,” and it is unclear why Anthem interpreted it as a specialist visit.
After KFF Health News contacted Anthem about Kovitch’s bill, Turner said that the company “should have identified the billing error earlier in the process, and we apologize for the inconvenience this caused Mrs. Kovitch.”
Caroline Cornish, a spokesperson for Maine Health, said that Anthem has denied coverage to patients who arrive without an appointment before. She noted that Anthem’s processing rules are sometimes incorrectly applied to these types of visits, leading to “inappropriate rejections.”
She stated that these visits should not require prior authorization and that Kovitch’s case illustrates how insurers often use administrative denials as an initial response.
“Maine Health believes that insurers should focus on paying for the care their members need, rather than creating obstacles that delay coverage and may discourage patients from seeking care,” she said. “The system, all too often, works against the people it is supposed to serve.”
Finally, in October, Anthem sent Kovitch an updated benefits summary, indicating that a combination of insurer payments and discounts would cover the total cost of the consultation. Kovitch said that a company representative called her to apologize. In early November, she received a $238 refund.
But she recently learned that, according to new rules established by Anthem, her annual appointment with the ophthalmologist now requires a referral from her primary care doctor.
“This remains the same,” she said. “But now I know better how they operate.”
