Pre-Authorization Denials

[24601NoMore]

Quote:

Originally Posted by sengsational This shows how broken the US sick care system is. If I didn't get free health insurance premiums, courtesy of the treasury, I wouldn't play (I'd go to a healthcare ministry). Even now, I'm looking for a subscription true "health care" practice (members pay a flat rate) rather than the typical "sick care" mega practices that spend all their energy assigning diagnostic and procedure codes. By the way, OP, you have very likely not seen the actual contract. It's probably something like 600 or 800 pages. I tried (unsuccessfully) to get a copy from BCBSNC. They gave one to the judge when I sued them in small claims court and it was like 3 inches thick. Even if you had it, I wonder if you'd be able to make any definitive statements about what the contract responsibilities are, as it's probably all legalese.

I'm also tempted by the health sharing ministries. BIL's wife is a member and seems to like it, but the lack of contractual obligation to pay is a pretty big risk, IMHO.

The "contract" I referred to is the Certificate of Coverage, which is something like 69 pages long. Sure seems from my experience with Fortune 500 contracts (a big part of my job prior to ER) that it's legally enforceable and pretty complete. It's stated in the CoC that they will approve "Medically Necessary" imaging. The issue here is that they attempt to redefine "Medically Necessary" to include additional things like a 6 week waiting period during which time they expect you to do a bunch of random, even more expensive than the MRI treatment on the off chance you get lucky and something works. Of course, by then, you could have spent 10X what you would have to get the MRI out of pocket. And, these random things attempted without an image to see if they will even work MAY make things worse, as the random activities are exactly that - purely random without an image to guide the healthcare provider in solving the underlying problem. So, I see it as just an intentional obstacle they throw in your way to get you to pay out of pocket vs putting it through insurance.

[Calico]

[MrsHaloFIRE]

I ridnt read the other replies but my first reaction is to go ahead and have them Dr prescribe something, almost anything, for 5 weeks thats a reasonable course if action. Notice I didn't say take it. Just have doc prescribe it. Wait your time. Tell doc its same. Yes I get that it wastes your time

Alternatively you can by an alacarte cash mri near me for like $300. Maybe thats an option.

[BoldPelikan]

My employer healthcare uses eviCore for pre-authorizations. DW has stage 4 cancer and we have a hell of a time every now and then getting things approved. No rhyme or reason, many peer to peer reviews, etc. Her oncologist ordered a brain CT prior to initiating systemic treatment, as per nationally recognized protocols. They denied it. After much haggling and review they eventually approved a brain MRI, which is more costly than a CT! We have had to delay scans and the whole situation just piles on to the stress. Now I start the calls to them about 10 days prior to a scheduled test. No fun.

[HGTVFanatic]

Quote:

Originally Posted by 24601NoMore Well the good news is that I found a MRI provider that my Dr likes who has a net cost difference of < $50 between contracted and non-contracted (ie: cash) prices for the two MRIs. That said, the $600 or so (combined) that I'd pay for the two (cervical spine and shoulder MRIs) wouldn't go against my deductible. Not that I'll ever reach my deductible anyway unless a catastrophe happens, so there's that. I guess my bigger issue is that this requirement for 6 weeks of "Dr. prescribed trial treatment" (PT, injections, etc) was not documented ANYWHERE in the contract. Or the marketing materials. MRI are "covered with pre-authorization". What they DON'T tell anyone is that pre-authorization includes things that many would not consider "Medically Necessary" (random PT..random injections..randomly prescribing pain meds). Instead, there are these hidden requirements that don't come up until you go to get pre-authorization, and then it's...SURPRISE! There's these ridiculous, unachievable hoops you need to jump through in order to even USE the insurance you're paying to get! And what's even WORSE - even jumping through the hoops doesn't "get me anything" other than credit against my deductible and a slightly better price, because I'll never hit the deductible and the insurance company doesn't have to pay even one cent ANYWAY! I did look up other insurance companies in my area as I think we can switch on the "A"CA until mid Aug, but none of them appear to be overall better. Most require PCP referrals to see a specialist (mine doesn't)..deductibles are similar or higher..and the real kicker - no other network takes many of our large # of doctors and specialists. So, I'm stuck having to jump through stupid hoops like spending $3,600 (6 weeks of 3 visits per week PT @ $200/visit) to get a $300 (literally) MRI approved. I'm obviously not going to do that so won't put the MRIs through on my insurance to get the deductible credit even though I'd still be paying 100% of the slighty lower, contracted cost, but what other undocumented surprises and unachievable obstacles am I going to run into with these guys as my insurance company? Terrifying stuff. Boy, do I miss corporate sponsored healthcare. It wasn't perfect, but it was LIGHT YEARS better than the "A"CA plans.

I was curious about your issue so I did some research. Please read this about shoulder injuries from someone injecting you too high. I cut and pasted important paragraphs from the link below. Make note of the prescribed treatment which your doctor may give you even without an MRI diagnosis.

https://link.springer.com/article/10...56-021-03803-x

A 61-year-old woman presenting with excruciating pain and tenderness at the injection site in her right shoulder within 30 min after receiving her first shot of COVID-19 vaccine (Oxford-AstraZeneca, Serum Institute of India). She voiced concern about vaccine administration, specifically that the injection had been administered “too high” in the arm. Informed consent was obtained from the subject described in this report.

Photographs of the patient while receiving the vaccine were taken and confirmation of the incorrect technique used was noticed. The injection was administered at the level of two fingerbreadths of the lateral border of the acromion, which is considered higher than the recommendation (Fig. 1).

The patient started prednisone oral treatment, vitamin D supplementation, and a physical therapy regimen to preserve the range of motion, in an attempt at minimizing potential complications, such as adhesive capsulitis.

[John Galt III]

OP, good luck! If I can just interject something here about pre-authorizations that might be of use to someone. I chose not to get a 'predetermination' (dental insurance term for pre-authorization, sort of) when I had a crown put on a tooth recently. I reasoned that I would have to get a crown anyway, whether or not they covered it. Plus, it would take a month of waiting with a broken tooth, just to get the predetermination answer. The ins co manual said it would be covered if it were medically necessary, and the clerks I called up said it would be medically necessary, 'probably'. I got the crown, and the ins co (Blue Cross Dental) denied it, 'based upon the plan's guidelines of medical necessity'. Even with the tooth half missing, and an xray showing that fact. My point is that I think had I taken the month to get a predetermination beforehand, it would have forced the ins co to either approve it, or if denying it, state the reason for the denial. Once my dentist knew why they would have denied it, he could have then made sure that all the ducks were in a row, and resubmitted another predetermination (another month wait, ugh) that the ins co could not now deny, since all the previously hidden 'ducks in row' were now known. The 'ducks in a row' are hidden inside the 'guidelines of medical necessity' that are not available to the dentist or the patient. Now that I think of it, maybe the ins co would refuse to say why they denied it, just repeat 'guidelines say not medically necessary, blah blah'. But maybe my strategy would work. As it is, my dentist is appealing the denial, and I may file my own appeal as well, if I think it will help. Good luck!

[Murph]

What I don’t get, is why are MRIs so darned expensive??

[Koolau]

Quote:

Originally Posted by BoldPelikan My employer healthcare uses eviCore for pre-authorizations. DW has stage 4 cancer and we have a hell of a time every now and then getting things approved. No rhyme or reason, many peer to peer reviews, etc. Her oncologist ordered a brain CT prior to initiating systemic treatment, as per nationally recognized protocols. They denied it. After much haggling and review they eventually approved a brain MRI, which is more costly than a CT! We have had to delay scans and the whole situation just piles on to the stress. Now I start the calls to them about 10 days prior to a scheduled test. No fun.

Yeah, you've got enough to think about without fighting with the insurance company. Always at the back of your mind is whether any delay (especially, based on denial/insurance co. fight/eventual diagnostics - or not) might adversely affect prognosis. While your doc is probably better at arguing your case, s/he typically has less time and (I would say, for the most part) is less emotionally invested. SO, it falls to you to make the phone calls, chase the question up the food chain (phone answerer, case worker, supervisor, director, etc. etc.) You can get burned out (and made sick yourself) from fighting for your loved one who probably is too sick to fight for herself.

I'm not saying denial is always the incorrect thing. But, if a qualified doctor, actually treating a patient in his/her office thinks a certain test or procedure is the correct one, I think the bean counters should typically err on the side of the doctor's call. What I would especially resent is the old "deny everything" and make the patient or doctor come back and try to wear down the insurance co. That's a lot of wasted effort and lost time when time may be the most important factor in treatment.

God bless you. Fight the good fight! We're at least here to listen and encourage.

[ERhoosier]

SIRVA used to be a "compensable complication of vaccine administrations in the US under the National Vaccine Injury Compensation Program. Unfortunately, that feature was dropped earlier this year.

https://en.wikipedia.org/wiki/Should...administration

(Not a big fan of Wiki, but this is a pretty decent synopsis).

Re- PT generally- Ortho docs can often prescribe some kinds of PT (e.g. exercises/stretches) to be done by the patient at home. That's what my Ortho did as part of my hand treatment a while back. Insurance co at the time accepted Ortho's prescription and note of my "compliance" as evidence of my 'trial' of PT.