Pre-Authorization Denials

[Ed_The_Gypsy]

That is our back-up plan as well.

This might be useless info but if you leave near the Mexican border an MRI will run you about 100USD SOB.

 

[Freedom56]

I have never heard of a preauthorization for an MRI or any test for that matter. We have a bronze PPO and with a $6600 deductible for each of us. An MRI is a pretty common diagnostic tool these days and are not that expensive if you are insured. My wife had one recently for her shoulder and the provider's full price was $1247 but the contracted rate with the insurance company was $332 which was what we had to pay and my wife's deductible was lowered by that amount. We didn't even contact the insurance company and wouldn't want them getting involved in medical decisions.

 

[MichaelB]

Terrifying stuff. Boy, do I miss corporate sponsored healthcare. It wasn't perfect, but it was LIGHT YEARS better than the "A"CA plans.

Despite the continuous protestations, your unfortunate issue is not due to the ACA. There are tens of thousands of different insurance plans around the country. It appears your coverage while employed was far more comprehensive and expensive, and you were not aware of the coverage differences when changing plans.

Deductibles, co-pays, and referrals are all aspects of health insurance plans determined by insurers and approved by state insurance regulators. Some state regulators have managed to get more and better options for their state residents, while others have not. It does seem many people who had employer provided health care insurance were not aware of the very high cost of that benefit.

 

[disneysteve]

The Dr. won't have the first clue what kind of treatment to suggest during the six week period without an image

That's not true. An MRI certainly isn't necessary to diagnose or treat most orthopedic problems. I'm old - 56. When I went to med school, we didn't have MRIs yet somehow we still managed to take care of all of our patients. MRIs existed, though they were called NMR at the time, but none of the hospitals where I trained had one. They were still pretty rare. A good physical exam diagnoses the vast majority of issues.

Also - the economics of this are crazy. I wound up around $300 for each MRI, for a total of $600. Every PT visit is around $200. If I did 6 weeks of PT, that's at least 2 and probably 3 per week for a total of let's say, 18 visits. That means the insurance company is actually saying "spend $3,600 (18 * $200) so that we don't have to approve a procedure that you'll pay $300 for..THAT'S INSANE and makes zero sense!!

You are absolutely right about this. I agree completely.


Years ago, there was one insurance company (Cigna) that wouldn't allow family doctors to order MRIs. There was no prior authorization process. We simply could not send a patient for an MRI at all. We had to refer them to Orthopedics. Guess what happened. Every single time I sent a patient to Ortho because I felt they needed an MRI, the Ortho ordered an MRI. So the insurance company got to pay for the scan AND the Orthopedic visit. How that saved the company any money I have no idea.

 

[Aerides]

That's not true. An MRI certainly isn't necessary to diagnose or treat most orthopedic problems. I'm old - 56. When I went to med school, we didn't have MRIs yet somehow we still managed to take care of all of our patients. MRIs existed, though they were called NMR at the time, but none of the hospitals where I trained had one. They were still pretty rare. A good physical exam diagnoses the vast majority of issues.

Agree, an MRI is only really helpful to the surgeon to proceed with surgery or more dramatic interventions. It's more confirmation than diagnosis. If any doc said "well I don't know we'll have to get an MRI to figure out what it could be and what to even start doing" I would run away. Or limp, since we're talking ortho docs

Symptoms alone usually tell them it's A, B, or C, at most. An Xray then gets it down to A or B (yes I know a lot of stuff doesn't show on xray, that's the point though, process of elimination). More often it's, yeah 95% sure it's A, we'll do an MRI if that means potential surgery.

PT or medication, rest, etc., are routinely prescribed following symptoms/xray, and those work for a good number of joint issues.

 

[RetMD21]

Yeah, I know that pre-authorization is required by virtually every (if not every) insurance company.

I guess what I'm new to is this requirement that you do other things first over a long period (in this case, 6 weeks),

Unfortunate that the weeks before your ortho appointment don't count. Sometimes this is a coding/documentation/communication issue. The doc can appeal to Evicore and often they will approve. Even a sub-MD level approval may go through if the office documentation is good enough.

 

[ExFlyBoy5]

I am glad that you are able to finally get an MRI.

My DW had persistant shoulder pain years ago. Repeated trips to the doc...xray after xray after xray. PT and then some more PT. About 2 months into this madness, I had a heart to heart with the medical group commander (this was military healthcare) about her care. All we wanted was a diagnosis...and I was fed up with the lack of one.

Long story short, I didn't get an Article 15 for being mouthy and DW got an MRI which showed a nasty spinal tumor. I could go on about the crappy health care she got in regards to her first surgery but I will hold my tongue. Bottom line is that had we not gotten very vocal about her condition, odds are she would be paralyzed from the neck down today.

 

[Koolau]

MRIs existed, though they were called NMR at the time, but none of the hospitals where I trained had one. They were still pretty rare. A good physical exam diagnoses the vast majority of issues.

Heh, heh, I still recall the break-room discussion when we first heard that NMR (Nuclear Magnetic Resonance) was going to be used on humans. In those days (in dose days) we put solutions into small tubes (a bit bigger than a typical mercury thermometer) and placed it into the the NMR instrument. The tube containing the solution was spun at (IIRC) maybe 50 - 100 rpm. We were trying to picture how this was to be done with humans.

If that's not funny, I guess you had to be there.

 

[Sunset]

I'm glad you found a place to get the MRI.


I have to tell you, though, that everything you've described is totally normal. It is not your specific insurance company. You've described the system with every insurance company I've ever dealt with, whether commercial or government-sponsored. Requiring prior auth for an MRI and that prior auth often relying on 6 weeks of conservative therapy is very much standard practice for most every insurance company.

+1
Mine made me do PT for many weeks before even approving an Xray -> which immediately showed I needed surgery.
Then the surgeon sent me for an MRI.

 

[disneysteve]

+1
Mine made me do PT for many weeks before even approving an Xray

Wow. I don't think I've ever had to get authorization for plain x-rays. It's only "advanced" imaging like ultrasound, CT scan, and MRI that they hassle us about.

 

[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.

 

[Sunset]

Wow. I don't think I've ever had to get authorization for plain x-rays. It's only "advanced" imaging like ultrasound, CT scan, and MRI that they hassle us about.

I have come to think it's somewhat random due to the complexity of all the factors.

For example another time, I tell a different doc about feeling I have a swallowing issue, so she immediately checks out my throat with an ultrasound machine. No approval even sought.

 

[disneysteve]

For example another time, I tell a different doc about feeling I have a swallowing issue, so she immediately checks out my throat with an ultrasound machine. No approval even sought.

That's a different situation. She owns/leases that machine. She bills for the ultrasounds she does but she doesn't need any approval to do one. I'm sure she knows that a certain percentage of them will get denied and she won't get paid, but it doesn't cost her anything other than her initial outlay for the equipment (and any ongoing fee). She doesn't pay per study.


When my wife was pregnant, her OB was a friend of mine. She got an ultrasound at nearly every visit. Most women only get a couple the entire pregnancy because that's all insurance will pay for. But he didn't care. He owned the machine. His only "cost" to ultrasound her was a few minutes of his time.

 

[youbet]

DW had spinal surgery a year or so ago. Microdiscectomy I think it was called. The steps leading to it were:

1. A round of steroids.
2. A round of steroids coupled with PT.
3. MRI
4. Surgery
5. PT

We were comfortable with that series of events. They stretched over several weeks but I don't recall exactly how many weeks at the moment. She got immediate pain relief after the surgery but spinal surgery was something she wanted to avoid if possible so tolerated the discomfort willingly while less invasive methods, that often worked on others with similar symptoms, were tried. Her Medicare Advantage plan covered everything once the OOP was met.

A related comment: I've always considered medical insurance something I carry to help me pay for medical expenses, especially BIG medical expenses. I seldom let coverage of small items (like a MRI) stop DW or I from choosing a treatment path and our primary care doc understands this. Doc does not consider uninsured expenses as something he'll have to eat. I pay them. But we do discuss in detail the whys and how much and various choices. DW's insurance is a Medicare Advantage plan and mine is traditional Medicare with a BCBS F supplement.

We feel fortunate for the coverage we have. DW, especially, has used a lot of medical services over the past 6 - 7 years. (Breast cancer, colon resection, spinal surgery, bunion surgery, rotator cuff surgery, female related surgery.) We've been able to pick and choose among providers without issue, paid little OOP considering the amount of all these bills, received what we consider to be quality care and so on and so forth. My only minor complaint is the cost: almost $20k annually for the two of us including my Part D plan and Part B and Part D IRRMA.

 

[24601NoMore]

Despite the continuous protestations, your unfortunate issue is not due to the ACA. There are tens of thousands of different insurance plans around the country. It appears your coverage while employed was far more comprehensive and expensive, and you were not aware of the coverage differences when changing plans.

Deductibles, co-pays, and referrals are all aspects of health insurance plans determined by insurers and approved by state insurance regulators. Some state regulators have managed to get more and better options for their state residents, while others have not. It does seem many people who had employer provided health care insurance were not aware of the very high cost of that benefit.

We have ONE - count them, ONE option for "A"CA coverage here that allows us to keep most of our Doctors.

I also wrote and reviewed pretty complex corporate contracts for Fortune 500 companies as part of my job before ER, so..yeah - I was pretty aware of the differences as I actually read and understood the "Certificate of Coverage" prior to signing up. Nowhere in there (as I posted previously) does it say you have to jump through arbitrary hoops such as 6 weeks of alternate treatments such as PT before they will approve an MRI. NOPE! The term used is they will approve "Medically Necessary" imaging - not "Medically Necessary" PLUS a bunch of random conditions that the insurer adds.

I also have pretty good insight into what the cost of the corporate coverage was, as I paid 100% of it during COBRA. The difference between that and the "A"CA plan (the whole 1 company we can choose from without losing all our doctors) is minuscule. Actually, it's almost immeasurable it's so small.

 

[24601NoMore]

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]

Can confirm - eviCore stinks

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]

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/10.1007/s00256-021-03803-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]

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/Shoulder_injury_related_to_vaccine_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.