Saturday, December 20, 2008
As Clear as the Colostomy Club's Swimming Pool
(Health Insurance companies pre-certification processes) We had a patient that no matter what we could not get an MRI pre-certified. If this is not done the insurance will not pay and the patient will get the full bill. Trying to stay up on all the latest hoops that the insurance companies want before they will approve a test is almost impossible. We try to get some kind of protocol but of course they will not release it. So, you can only find out by trying. If you do get something in writing from them it is about as clear and the colostomy club's swimming pool. This is usually how it works. If we order a MRI, our team has to call the insurance company, then fax the clinic notes. A person at the insurance company who has no medical training then looks the notes over and checks to see if the right words are there and if there is the correct previous tests and then checks her protocol to see if it can be approved. (the protocol is not to be distributed outside of the insurance company). They then automatically deny the request unless it is 100% within their protocol. This is becuase they make sure the responsibility of getting the test approved is on the physician, not the patient. (If you make it hard to get a test, the office will not order them. Keep the hassle away from the patient so they think they have great insurance.) So, we get the denial and then have to talk to someone else to find out what else they need. They also have no medical training, This goes nowhere becuase you cant explain to them that the test is needed because you think the patient has a brain AVM and might stroke out. All they say is that if we think the patient really needs the test they should get it done and pay out of their pocket or go to the ER. Finally, in the battle you get a manager who will let you talk to the medical person who has authority to approve the test. This will always have to be scheduled at a later date to make it as inconvient as possible. (Another trick to see if yo will just drop it.) This is supposed to be a peer to peer, but the person you talk to usually has no clue what you are talking about. (The classic was a retired OB and I had to talk to him about a tumor of the skull base!) Finally, the insurance company will pre-cert the test. This whole process took one of our office staff three hours and me 30 minutes on the phone. All this for one test!