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!

1 comment:

SeaSpray said...

First of all... the average patient can't pay out of pocket for an MRI (and should not have to if they have insurance), so they would probably exercise option #2...go to the ER.

That is a flawed option though... because it will cost the insurance company and the patient MORE money.

The patient will have copays for the use of the ED, out patient tests (likely to be labs with it)and whatever else the ED physician deems necessary even if he/she doesn't do to the CYA factor and the ED physician's bill.

So... what you are saying is that the insurance company prefers to pay their employees additional working hours to deflect accepting the claims for as long as possible,and the additional charges of added OP tests that would surely be ordered through the ED, the hospital ED charge, the emergency physican's charge along with the inevitable MRI charge as opposed to just paying the claim on the MRI test. ?

Well..that's logical. I really don't understand what your complaint is here Throckmorton. ;)

Seriously though... why is it not mandatory that insurance companies release their protocol?

I have read a lot of med blogs over the last 26 months regarding the insurance companies. I feel very frustrated when I read these things because there are rules and regulations for everything and I just don't understand why when it comes to insurance company reimbursements or precert approvals the providers have to muddle through the perpetual quagmire of denials. The most ridiculous one I heard and I said it here but was where I.U. said they got a precert approval for him to do the surgery, but then denied the claim AFTER he performed the surgery the insurance company APPROVED.

(Okay..if I were the doctor receiving that denial...I would internally be reacting like Steve Martin in Planes, Trains and Automobiles when he realized the car that was damaged and on fire was charged to his credit card. He was doing all kinds of gyrations in absolute frustration. :)

But then I'U's office staff had to resubmit it...denied again...when the Insurance company PREVIOUSLY APPROVED IT "PRIOR" TO SURGERY!

That is where I would internally feel like Steve martin at the airport...when he was seething at the happy car rental lady. :)

So...I.U. was finally paid SIX months later!!!

Maybe I am slow on the uptake of this...but I really do NOT understand how that could happen and why it would take SIX months to be paid. It's not rocket science. It seems pretty black and white.

How can they not release their protocol?

I am thinking of that youtube "5 star rules" where they can change the rules at any time. you have any idea why this is tolerated?

I am truly perplexed and baffled. It is so important and should not be this way. I have visions of your team having to don their combat gear before they pick up the phone to go to war with the insurance companies.

I only did admission precerts and they were so easy as long as you gave them the required info, but it was clear.

I have had a lot of tests that required precerting by my physician's office and have no idea if it was difficult. I know I called a couple of times for things, provided the dx/code and they approved instantly. And I told you the receptionist said my plan paid them in 2 weeks. But that last year we had fed high option bc/bs (1988) they denied 2 significant claims that I had to go after them on and then it was a chance meeting with someone from their company that resolved the last claim for me. My only other alternative was to write to Washington DC..their main headquarters...which I was going to do. (That is when I learned to never accept no, but to pursue the claim. just know what your manual says.)

But you can't because they don't tell you!

Isn't that illegal? Withholding information?

I guess you all are used to this being the status quo... but and I keep saying this...I don't understand why physicians don't unite and start a grassroots resistance to the truly inane and erroneous insurance practices and the same with JCAHO regulations. ?

I guess it is all just so big and out of control. But change has to start somewhere.