Her health insurer delayed her MRI — as the cancer spread

Plus: N.C. hospitality industry seems OK with bill to extend Mecklenburg taxes; Reval reviews on pace with 2019; 16-year-old scooter rider killed; Teen driver's license changes; Crumbl in Midtown

May 08, 2023

Today's Charlotte Ledger is sponsored by T.R. Lawing Realty:

A North Carolina bill aims to reduce wait times for insurance approvals; ‘They deny and delay and hope you go away’

Kathleen Valentini and her son Matthew in October 2020. It took 41 days for her health insurer to approve the MRI that diagnosed bone cancer. By then, doctors said they needed to amputate her leg and hip.

By Michelle Crouch

Co-published with North Carolina Health News

Kathleen Valentini was 47 when she first noticed a nagging pain in her hip. The Waxhaw mom tried physical therapy, but her pain just got worse. Her doctor ordered an MRI to find out what was going on, according to court documents and Kathleen’s husband, Val Valentini.

But Kathleen’s health insurer wouldn’t authorize the MRI, a scan that can cost as much as $8,000. After considering the request for two weeks, the insurer said the procedure wasn’t “medically necessary,” her husband said. It ordered her to try six weeks of physical therapy first.

Kathleen already had done that, however. The insurance — which came from her husband’s former employer, the New York City Police Department — even covered it.

The Valentinis appealed. Four weeks later, 41 days after the doctor first sought an MRI, the insurer reversed its decision.

When Kathleen finally had the MRI in March 2019, it revealed an aggressive type of bone cancer. Kathleen went to Memorial Sloan Kettering Cancer Center in New York for treatment. The doctors said they needed to amputate her leg, hip and pelvis.

Then they said something that was almost more devastating, Val said: that if Kathleen had come in even a month earlier, they probably could have treated the cancer using only chemotherapy.

Kathleen underwent the amputation and had several rounds of chemo. It wasn’t enough to stop the cancer. She died in November 2020.

“I’m convinced that the delay caused her death,” Val told The Ledger/N.C. Health News recently. “They deny and delay and hope you go away. It is just wrong.”

Law would create new rules for insurers

Kathleen’s case is extreme, but it underscores why many patients and doctors are frustrated with the process insurance companies use to decide whether to pay for specific treatments. It’s called “prior authorization” or “utilization review.”

Now, North Carolina lawmakers — along with those in about two dozen other states — are considering changes to overhaul that process. The legislation requires insurance companies to act faster.

Prior authorization is supposed to prevent doctors and hospitals from recommending expensive and unnecessary procedures. But doctors say prior authorization can keep people from getting life-saving treatments and drugs, sometimes without explanation.

“Doctors are frustrated,” said Chip Baggett, CEO of the N.C. Medical Society, which is advocating for the legislation. “They go to school to be trained to pick the best therapy for their patients, and someone else from far away is deciding whether their best medical judgment is right.”

Sometimes, he said, the person making the decision for the insurance company is not a physician. Other times, they have no expertise in the medical specialty in question.

About 94% of physicians nationwide report delays in care associated with prior authorization, according to a 2022 survey of 1,001 physicians conducted by the American Medical Association. And 1 out of 3 doctors in the same survey say it’s led to serious medical problems for patients.

Health insurers: Prior authorization helps patients

Health insurers say prior authorization protects patients from expensive and unnecessary care, as well as from medical errors.

In a letter opposing the legislation, America’s Health Insurance Plans (AHIP), a national association of health insurers, shared the following examples of ways prior authorization helps patients:

(Prior authorization) can help ensure safer opioid prescribing; help prevent dangerous drug interactions from antibiotics and other infection fighting drugs; and help protect patients from unnecessary exposure to potentially harmful radiation from inappropriate diagnostic imaging, such as CT scans for back pain.

The letter said as many as 1 in 4 prior authorization requests insurers receive are for care that is not supported by medical evidence.

Administrative headaches

Physicians of all specialties say they are spending a growing amount of time trying to persuade insurance companies to approve care, Baggett said. Many doctors have had to hire additional staff just to handle prior authorization reviews, increasing health care costs, he said.

Dr. Christopher Tebbit, an otolaryngologist (ENT) with Charlotte Eye, Ear, Nose & Throat Associates, said insurers usually approve his requests for care — but only after he and his staff go through a time-consuming, bureaucratic process. He said he spends several hours on the phone each month in “peer-to-peer” conversations with insurance company reps.

“I’ll say, ‘I don’t know why we are having this call because you’ve approved this same type of procedure for this same type of patient over and over,’” Tebbit said. “It creates a two- to three-week delay in care for no discernible reason, and it takes me away from patients.”

What the legislation would do

The North Carolina legislation, House Bill 649, was approved unanimously by the N.C. House on April 26 and is awaiting consideration by the state Senate. Here are a few key provisions of the bill:

Discussion with the doctor: If an insurer is questioning the medical necessity of a treatment or service, they must notify the patient’s medical provider within five business days and give the provider an opportunity to discuss the decision.
Time limits for reviews: Insurers must issue a decision about urgent medical services within 24 hours after receiving all of the information about the case and make decisions about non-urgent medical services within 48 hours.
Only MDs can do reviews: Those who deny or approve medical treatments on behalf of insurers must be actively practicing physicians licensed in North Carolina who have experience in the specialty or treatment in question.
Physician exemptions: Doctors would be exempt from prior authorization requirements for a particular health care service if they have an 80% prior authorization approval rate for that service over the past 12 months. (This is sometimes called a “gold card” law.)

New laws speed up the process

AHIP spokeswoman Kristine Grow expressed particular concern about the physician exemptions. Texas has a similar law, but doctors there need a 90% approval rate to be exempt.

“Patients deserve better than doctors who get their care wrong 20% of the time,” Grow said. “We can’t in good conscience support proposals that would give such a free pass on patient safety, efficacy and value.”

Besides Texas, several other states have approved laws targeting prior authorization rules, and about 20 more are considering legislation, according to the American Medical Association.

In recent months, as calls for change have gotten louder, at least three insurers — UnitedHealthcare, Aetna and Cigna — have voluntarily announced that they are making changes to improve their prior authorization processes, according to the The Wall Street Journal.

“We’re not deaf to the complaints out there,” Philip Kaufman, chief growth officer at UnitedHealthcare, told the Journal. “We’ve taken a hard look at ourselves and this process.”

Still denying tests

The Valentinis moved to Charlotte in 2013 after Val retired from the New York City Police Department. Val said he had always heard that the department’s health insurance for retirees, provided by Group Health Inc. (GHI), was good.

In Waxhaw, Kathleen homeschooled their teenage son, Matthew. In her free time, she loved to bake, and she volunteered at St. Matthew Catholic Church. She also coordinated neighborhood efforts to prepare meals and kits for homeless families.

“She never did anything for herself,” Val said. “She always did everything for everybody else.”

After the amputation, Val said the battles with GHI continued.

“When she was still in the hospital after having a 20-hour surgery to remove her leg, hip and pelvis, her doctor was telling me they were still denying tests,” Val said.

Val and Kathleen filed a lawsuit against GHI in October 2020. Among other claims, the suit alleged GHI appeared “to be engaged in a systemic effort to delay or block necessary medical treatments and services and defeat their contractual obligations.”

GHI’s parent company, New York-based EmblemHealth Inc., declined comment, citing HIPAA privacy laws.

The Valentinis lost their case in district court, and in February, the 2nd U.S. Circuit Court of Appeals declined to overturn the verdict. In their decision, the appellate judges noted that the insurer never advised Kathleen on a course of treatment, and that insurance reviews do not, in and of themselves, subject patients to physical harm. Rather, they are a service to ensure people are reimbursed for contractually covered medical care.

Ultimately, the judges said, the law “cannot be stretched” to allow the court to hold insurance companies liable in cases such as Kathleen’s.

“The judge said it’s a travesty,” Val said, “but that (the insurance company) didn’t break any law.”

That’s why prior authorization reform laws like the one being considered in North Carolina are important, Val said. They may be the only way to hold insurance companies accountable, he said, and “the system needs to be changed.”

Michelle Crouch covers health care. If you have tips or ideas for her, please shoot her an email at mcrouch@northcarolinahealthnews.org.

This article is part of a partnership between The Ledger and North Carolina Health News to produce original health care reporting focused on the Charlotte area. For more information, or to support this effort with a tax-free gift, click here.

Today’s supporting sponsor is CLT Public Relations, the experts in Charlotte politics. Specializing in municipal lobbying, real estate advocacy, public affairs management and professional networking within the greater Charlotte Region.

Key N.C. hospitality association says it’s unlikely to oppose bill extending Mecklenburg taxes; money for Panthers deal?

The head of North Carolina’s largest hospitality industry association is asking for more time to digest plans to extend Mecklenburg taxes on dining out and on hotel stays — but says her association is unlikely to oppose them.

Lynn Minges, CEO of the N.C. Restaurant and Lodging Association, told The Ledger in an interview on Friday that although the association typically opposes new taxes on meals and lodging, a bill backed by the city of Charlotte and local hospitality interests is different. The bill, which surfaced in a committee meeting in Raleigh last week, would extend until 2060 a pair of taxes collected in Mecklenburg that are set to expire in the 2030s, and it has the backing of local business leaders in the hospitality industry.

“This is a bill we would likely not oppose,” Minges said.

The acquiescence of the association to the bipartisan bill removes a potential roadblock to its becoming law. Tourism taxes, including the extension, are thought to be a key component of what the city could offer the Carolina Panthers in an economic development package to renovate Bank of America Stadium and build a training facility nearby.

Reports last week by WSOC and the Charlotte Business Journal indicated that city leaders have discussed providing $600M in public money as part of a $1.2B economic incentive package. Hospitality taxes can be used only to support tourism-related projects.

Minges said she talked last week with the bill’s lead sponsor, Republican Rep. John Bradford, who “agreed to kind of slow the bill a little bit to give us some time to digest it, to ask them questions and discuss it with our members.” She said she wanted to make sure that there would be “tourism leaders around the table helping to shape and guide and offer feedback into what kinds of facilities are needed and how these investments need to be made.”

The N.C. Restaurant and Lodging Association represents about 20,000 hospitality-related businesses statewide and is active in lobbying in the General Assembly.

At issue is extending a 1% charge on prepared food and drinks, as well as a 2% charge on hotel and motel stays. Several local small businesses have told The Ledger they consider the 1% tax “annoying,” because they have to distinguish between items that are and are not subject to it.

Local business leaders also support extending the taxes. The Charlotte Regional Business Alliance, which counts many large Charlotte businesses among its members, is “hugely supportive” of the bill, says Joe Bost, the alliance’s chief advocacy officer.

“What the tourism and hospitality industry has done for the Charlotte region is just absolutely phenomenal,” he said. “They have helped set the Charlotte region apart.”

In addition to the Panthers’ stadium, other potential beneficiaries of tourism tax money could include the old Eastland Mall site, Discovery Place, the NASCAR Hall of Fame and a pro tennis project at the new River District west of the airport. (We’re hearing there could be more info coming out on that this week.) —TM

Related Ledger articles:

“City’s plan for Panthers’ stadium renovation leaks out: $600M in public funds, matched by team” (🔒, May 5)
“Crescent’s River District is open to including a sports complex” (🔒, April 5)

Informal reviews of revaluation same as 2019, county says

Mecklenburg County received about the same number of requests for informal reviews of property values as it did in the last revaluation, in 2019.

Some 14,939 property owners this year requested that the county review records related to mistakes in property valuations, such as the incorrect amount of square footage of a house. In 2019, there were 14,400 such requests. An informal review allows the value to be corrected without going to a full-blown appeal of a property value.

The deadline for informal reviews passed last month. The deadline for appeals of property values is June 9.

Valid reasons for appealing include a valuation that is above the market value as of Jan. 1, or a valuation that is out of line with similar properties in the neighborhood. An inability to pay or a steep increase from the most recent revaluation is not a valid reason for an appeal.

The county released new property values for more than 400,000 parcels in March, which will be used to determine the amount of property taxes landowners pay. Property values increased by an average of 51% since 2019.

For more info, go to the county’s revaluation website. —TM

Related Ledger article:

“It’s revaluation time: 4 things to know” (🔒, March 17)

🎧 New podcast episode: Kimbo Bohannon of Buddy/Mentor

In the latest episode of The Charlotte Ledger Podcast, Kimbo Bohannon discusses how she started a nonprofit mentoring program for elementary students called Buddy/Mentor — and the importance of students knowing someone is cheering them on.

➡️ Listen here, or find The Charlotte Ledger Podcast on major podcast platforms.

You might be interested in these Charlotte events: Business webinar, music at SouthPark, preservation celebration

Events submitted by readers to The Ledger’s events board:

WEDNESDAY: Business Toolbox webinar: Avoiding Legal Headaches. 12:00 to 12:45 p.m., online. Join The Charlotte Ledger and the employers association Catapult on the first of three free weekly lunchtime webinars designed to help businesses navigate common challenges. Up first: “Build a Compliant Business: Tips to Avoid Legal Headaches.” Registration required. Free.
THURSDAY: SouthPark After Five, 5-9 p.m., Symphony Park. Free live music, food trucks and drinks, and hands-on art experiences are coming to Symphony Park at SouthPark After Five on May 11. Enjoy music from Sol Fusion. Plus, learn how to screen print your own SouthPark tote bag with MacFly Fresh Printing Co.! This event series will continue every Thursday through June 1. Free.
THURSDAY: Charlotte Gem Preservation Awards, 6-10 p.m., Charlotte Museum of History. Celebrate Charlotte’s history and culture through live performances, tours, music and more at the Charlotte Gem Preservation Awards. $75-$200.

◼️ Check out the full Ledger events board.

➡️ List your event on the Ledger events board.

In brief:

Shorter wait for teen drivers’ licenses: Starting today, teens in N.C. can receive a provisional driver’s license after 6 months of a learner’s permit instead of the usual 12 months. The duration expands to 9 months starting in early 2024. It was temporarily reduced to 6 months during the pandemic. (WTVD)
Teen killed in scooter accident uptown: A 16-year-old riding a Bird electric scooter died Saturday after colliding with a Dodge truck in uptown Charlotte, police said. The crash took place at the corner of Mint Street and Martin Luther King Boulevard at about 6:30 p.m., an hour before kickoff of Saturday’s Charlotte FC game. (WSOC)
Social districts envisioned in uptown, South End: Charlotte Center City Partners says it has filed preliminary applications to allow portions of uptown and South End to become social districts, where people can walk outside legally with open containers of alcohol. Others have filed applications for parts of Plaza-Midwood and LoSo. (Axios Charlotte)
Milestone for Charlotte neighborhood bar: Brawley’s Beverage on Park Road celebrated its 20th anniversary this weekend, and an article in Charlotte magazine says it’s “the closest thing to Cheers we’ll ever get.” Brawley’s doesn’t sell Bud Light, Coors or Miller Lite, and a “No Big Beer” sign hangs above the bar. “If a craft brewery sells to one of the large conglomerates, those beers are quickly marked for discount and deliveries halted,” the article says. (Charlotte magazine)
City sues vendor over CATS ads: The city of Charlotte is suing the company it hired to sell ads on buses and light rail trains, saying Vector Media Holding underpaid the city by more than $1.5M. A Vector spokesperson said the dispute stems from the “significant reduction” in public transit service during the pandemic. (Observer)
Medical marijuana plans in limbo: The chief of the Eastern Band of Cherokee Indians vetoed spending on a medical marijuana superstore, saying it was over budget and had a “lack of accountability.” The dispensary was scheduled to open later this year, and it’s unclear what the move means for the store’s future. The site of the planned store is in Cherokee, three hours west of Charlotte. Medical marijuana was recently approved for tribal land but is not legal in the rest of N.C. (Observer)
Cam’s style hindering NFL return? Former Panthers quarterback Cam Newton said in a recent podcast interview that he thinks his fashion and hairstyle have affected his chances to return to the NFL. “It’s been hindered, and I’m not changin’,” he said. He added: “Right now, where I’m at, it’s about embracing who I am.” (Yahoo Sports)
Cookie news: A Crumbl Cookies store has opened in Midtown, at 337 S. Kings Drive across the street from the Metropolitan — apparently in the last few weeks, The Ledger has learned. The expanding cookie chain has 10 stores in the Charlotte region.
Robot waiters in Pineville: An Asian restaurant in Pineville uses two robots named Wall-E and Eve to deliver food to tables. The owner of Yiding Hot Pot says the robots are “very helpful to the restaurant to reduce the labor.” (CharlotteFive)

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