If you are scheduled to get an elective procedure, make sure that you have done your homework beforehand or you may find yourself stuck with large bills and little recourse on challenging them.
Many insurance plans require something called “prior authorization” from a primary care physician before they will pay for elective procedures. But many patients are not aware that they need prior authorization and treating physicians may not be aware of this either.
Jake (not his real name), a lawyer at Stanford University, shared his experience with this process. I happened to be sitting next to him on a plane flight to Boston. He had been scheduled for a procedure that his doctor urged him to get the next day. But first he called his wife, a physician at Stanford. She told him to call their insurance company immediately for prior authorization.
“The doctor wasn’t happy,” he said. “It delayed the procedure. But fortunately it wasn’t super-critical that my procedure be done immediately. It required waiting a few more days, but I got the authorization.”
It could potentially have made a huge difference, however, to his wallet: without the prior authorization, he said, he could have wasted months afterwards contesting medical bills—and perhaps not getting them reversed.
There is little protection from or information about this process. Patients sign a blanket waiver when they get a procedure, stating that they are personally responsible for the charges should their insurance company not cover them. So clinics and hospitals are off the hook—and they can blame the patient for not doing due diligence.
The insurance companies, likewise, are off the hook—they can say that it clearly states in the insurance policy that prior authorization is required before any procedure.
The problem is that few patients have ever seen their insurance policies; and requesting them—let alone reading and accurately interpreting them–can present challenges also.
This doesn’t apply just to procedures like colonoscopies but to surgeries and medical appointments with specialists also, particularly if the specialist is out of network. One of my clients, “Robert” (not his real name), was initially denied insurance coverage due to lack of prior authorization for an infectious diseases consultation required for a complex surgery — until I reached out on his behalf to help rectify the matter. Robert had not understood that he was required to get prior authorization. This added considerably to his level of stress–which was already sky-high due to many other issues related to the surgery. It was hard for him to cope with the anxiety around a potential insurance denial on top of everything else.
What’s an informed patient consumer to do? It is prudent to check with your insurance company before any elective procedure—and document the call and the person you are speaking with. Prior authorization is generally not required in the event of a life-threatening emergency–but it is still prudent to check with one’s insurance as soon as possible following an emergency situation that leads you to seek medical care since definitions of “life-threatening” can vary.
Dr. Danielle Ofri, Assistant Professor at NYU observed in a New York Times article that problems around prior authorization occur with medications also–although as a rule with medications, it is apparent at the pharmacy cash register that insurance has been denied, not months later when a bill arrives. She concludes: “In the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.”
Until things change–patients need to be aware so they can protect themselves.
If prior authorization is required, obtain the necessary referral from your primary care physician and insurance approval before proceeding. This may seem like a lot of work—but it’s much less stressful than facing medical bills that have been declined by your insurer due to lack of prior authorization.
Disclaimer: All patient names and identifying details have been changed to protect client confidentiality. The suggestions given here are not intended as a substitute for the medical advice of your physician.
