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Posted on 27. August 2010

Preauthorization Not Required

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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Categories: Need to Know

Comments (4) -

5:52 AM on Wednesday, September 01, 2010

As a patient, I have not had any negative experience with prior authorizations (recently my IVIG went to PA), but honestly, everything I've ever needed a PA for (IVIG, CT) had rock solid evidence...but I've seen where someone had a pain or a 'twinge' and the doc I work for have to fight like hell to get one. And while I would never lie, I do sometimes stretch the truth or exaggerate the symptoms.
And when the result shows comes back with something (god forbid) I want to call them back and yell at them for even doubting the reason! lol
Take care and hope you're feeling well.

3:57 PM on Wednesday, September 08, 2010

eye opening amd good imformatiom to have for the future medical needs for myself. I will be more diligent in reading the fine print.
This reminded me of another double standard we are faced with--that if medical reform that the populace of the sounrty are suppose to be happy with, but members of congress and their families don't have to put up with.
I liked life when it was simpler!

6:39 AM on Wednesday, December 01, 2010

My husband and I got news that he was losing his insurance, I have medicare HMO, I have IVIG (privigen). Was told that since I lost my primary, I need to go to the hospital and have the treatments done there, and not in an infusion setting.
My treatments cost $35,000 for one time, and was told that I have the treatment and have the hospital bill medicare then they will determine how much and if they are going to cover.
We dont have that kind of money. Even when insurance does pay I will have to pay 20% out of pocket for each infusion which is 7000.00 dollars plus any deductible, co-insurance.
Its very frustrating.  My husband has Lukemia also, so he has large amounts of medical bills.

Alot of people think oh it will never happen to me, well it does.  A bit of advice is to think about the far future and what could happen.

9:51 AM on Friday, September 23, 2011

After being preapproved to go to Mayo clinic for testing, i had to spend months getting my insurance to cover my expenses there,, I was getting collection agency calls,, hours spent on the phone, casewrokers who promised to get back to me the next day,, they never did,, only after i contacted the state insurance agency did it get straightened out, now that my good insurance is running out, my treatment is getting worse, i have a IGG2 and Igg3 deficiency that no one will treat,, the immuno wont treat it, and now I get something today say I have fusurium fungus growing in my sinuses,, and after calls to ent,, they said dont worry about it,, no I am not a bad patient,, just a frustrated one,,

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