Beware the Prior Authorization
When your health insurance company asks your doctor to submit a prior authorization for a procedure, test, or treatment, it is not just a formality or a technique to make your doctor’s life more difficult. The request for prior authorization is a signal that there are conditions under which the insurance company may deny you coverage.
The prior authorization is a cost saving tactic used by the insurance companies to deny coverage for the more expensive treatments. In spite of what they may say, it is far more about maximizing the insurance company’s profits and far less about your health care. I don’t think that comes as much of a surprise to anybody.
Once the insurance company denies a prior authorization, you are left with the decision to start the appeal process. The appeal process is designed to put more hurdles in front of you with the insurance company hoping that most people will give up rather than try to jump over the hurdles. And again, when a subscriber gives up, the insurance company has avoided paying one more claim, which leads to more profit for the insurance company at the expense of your health care.
The best thing to do is to nip the whole thing in the bud. When your insurance company requests a prior authorization, you and your doctor need to figure out under what conditions the insurance company will pay for the treatment. If your diagnosis is not 100% certain, the doctor may have the leeway to choose an “approved diagnosis” – one for which the insurance company will cover the prescribed treatment.
It is possible that your doctor wants to try a treatment and use the results of the treatment in order to make a more accurate diagnosis. Take the example where your doctor prescribes a prescription medication. If the medication works, the doctor infers that you have the condition that the drug is proven to treat. This technique is safer and less expensive than exploratory surgery. But to get the drug covered, the doctor may need indicate in the prior authorization that he or she has made the diagnosis that the drug was designed to treat even though he or she is not yet 100% sure.
Arming yourself with the list of “approved diagnoses” is the trick. The first place to look is your insurance plan’s coverage documents. But that may not include all the details that you need. You can also check the Internet. It is surprisingly easy to find information about prescription drugs and the conditions for which they are approved by the FDA. Your doctor can also check the Physicians Desk Reference. Keep in mind that a diagnosis by itself may not be sufficient. Treatment may further be restricted by a combination of diagnosis, age, and gender of the patient.
If the prior authorization is denied and you find yourself deciding whether or not to appeal, make sure you understand exactly why the insurance company denied coverage. In your appeal letter or phone call, ask the direct question – “Under what circumstances would this treatment be covered?” If you and your doctor can argue that you meet those circumstances, you should say exactly that in your next appeal letter and your doctor should write a note to the insurance company saying the same thing. Be sure to keep your records. Once you have a record showing that your situation matches their coverage conditions, the insurance company will be hard pressed to deny your claim any longer.
