By Kris McFalls
It can be a patient’s worst nightmare. Imagine having a medical procedure performed only to find out afterward that the insurance company won’t cover it. This seems to be happening more and more frequently. With medical costs skyrocketing, insurers often require preauthorization for expensive tests and procedures - but not always. And that’s where the trouble arises. Patients, then, would be wise to have all non-emergency procedures preauthorized by their insurance before agreeing to services. I recently had the opportunity to put this sage advice to work.
After years of hip pain and ineffective treatment, I sought the opinion of an orthopedic surgeon whom, for the purposes of this blog, I will call Dr. Hip. An MRI soon revealed that the best way to fix the problem was surgery. Dr. Hip’s assistant faxed a full report to my insurer with the title “Predetermination Requested” at the top of the page, along with the appropriate radiology reports. About a week and a half later, I received a letter in the mail from my insurance company, which stated, “We received the request from Dr. Hip and have determined the procedures Dr. Hip plans to perform do not require preauthorization.” Wonderful, I thought. That is until I read a little further. “This letter does not constitute guarantee of payment, nor does it determine medical necessity, which will be determined after the claim is made.” What? After the claim is made? Isn’t that kind of like guessing the lottery numbers after the drawing? Wow, what a great system these guys have. I want in!
I called the insurance company and insisted they level the playing field. If Dr. Hip has to make a decision of medical necessity based upon an exam, MRI scans and X-rays, then the insurance company should have to play by the same rules. Dr. Hip’s assistant agreed, and she too called the insurance company and asked them to review the case again. She was told, in confidence, that people receiving these kinds of faxes don’t actually read them if the codes don’t require preauthorization. Let’s turn the tables here: What if doctors did that? Suppose the doctor said, “Well, Kris, I didn’t actually read the MRI, so I don’t really know if you need surgery, but we are going to go ahead with an invasive procedure to determine if your hip truly requires it.” I seriously doubt any patient, or even insurer, would allow that.
Nonetheless, in this particular situation, the insurance representative was very understanding and told Dr. Hip’s assistant that if she wrote “Courtesy Predetermination Request” in large letters across the fax, the insurance would take another look. Somehow, changing the title to include the word “courtesy” was pleasing to the insurer, which finally did agree beforehand that my surgery was indeed medically necessary. Of course, the letter of authorization still included lawyer-speak that stated, “Authorization does not constitute guarantee of payment.” However, Dr. Hip’s assistant and I felt more confidant that moving forward wasn’t likely to leave either one of us in financial ruin.
Although final payment is never 100 percent guaranteed, persistence and careful planning can help. What experiences do you have involving insurance preauthorization?
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