I'll go first. I did lots of policy writing, and SOP writing with a medical insurance company. I was often forced to do phone customer service as an "additional duties as needed" work task.
On this particular day, I was doing phone support for medicaid customers, during the covid pandemic. I talked to one gentleman that had an approval to get injections in his joints for pain. (Anti-inflamatory, steroid type injections.) His authorization was approved right when covid started, and all doctor's offices shut the fuck down for non emergent care. When he was able to reschedule his injections, the authorization had expired. His doctor sent in a new authorization request.
This should have been a cut and dry approval. During the pandemic 50% of the staff was laid off because we were acquired by a larger health insurance conglomerate, and the number of authorization and claim denials soared. I'm 100% convinced that most of those denials were being made because the staff that was there were overburdened to the point of just blanket denying shit to make their KPIs. The denial reason was, "Not medically necessary," which means, not enough clinical information was provided to prove it was necessary. I saw the original authorization, and the clinical information that went with it, and I saw the new authorization, which had the same charts and history attached.
I spent 4 hours on the phone with this man putting an appeal together. I put together EVERY piece of clinical information from both authorizations, along with EVERY claim we paid related to this particular condition, along with every pharmacy claim we approved for pain medication related to this man's condition, to demonstrate that there was enough evidence to prove medical necessity.
I gift wrapped this shit for the appeals team to make the review process as easy as possible. They kicked the appeal back to me, denying it after 15 minutes. There is no way it was reviewed in 15 minutes. I printed out the appeal + all the clinical information and mailed it to that customer with my personal contact information. Then I typed up my resignation letter, left my ID badge, and bounced.
24 hours later, I helped that customer submit an appeal to our state agency that does external appeals, along with a complaint to the attorney general. The state ended up overturning the denial, and the insurance company was forced to pay for his pain treatments.
It took me 9 months to find another 9-5 job, but it was worth it.
Got pulled off all of my R&D projects and told by the CEO in a meeting with all of the team leaders (who enthusiastically agreed) to focus entirely on this one project as it was critically important and mandatory whether we liked it or not before we could go to market with our product. Said OK, got it ready in record time, none of the managers wanted to approve testing. Got told a generic “We need more info.”
Fleshed out everything I could. Did all sorts of bench top testing with full reports, did thorough budget analysis for the entire thing, a complete gantt chart with every contingency accounted for.
Two years later I’m in the latest of god only knows how many approval meetings with management. I’ve dialed back how much I expect out of them and I’m just trying to get an official project initiation form signed so at least I have a record of them acknowledging the project’s existence. One of them asks, for the nth time, “Why do we need to do this again?”
Boss looks at me expectantly, like “Yes, why do we need to do this?” as if I was the one who put myself on the project. I said “I can forward you the email where you told me to drop everything and work on it. If you changed your mind I’m more than OK to drop it and work on something else, but I refuse to hold even one more meeting to get agreement that I should even be working on this.”
He says “I think we just need more information.” I ask “Such as?” knowing full well there wasn’t a single more thing I could add. “We just need more information.” All of the team leaders just stared at me. So I quit on the spot and walked out.
Talked to a friend who still worked there and they still haven’t moved forward with that project years later, and the governing body still refuses to allow sale of the product until they do. It’s a 2 year timeline for testing so I have no idea what they are thinking. It’s only $100,000 too, they paid me more to try and get approval for two years than it would have cost to do it in the first place.
The answer is "we need data that matches what we want".