behind the scenes, insurance insanity, primary care

Whoops, They Did it Again!

Medications are not the only things that need “prior authorizations.”  Radiology studies are another one.  Now, if I see a patient and decide they need a CT or MRI scan, you’d think I just order it, right?  Wrong.  I order it.  Then someone from my staff attempts to obtain prior approval for it.  This involves sitting on hold for endless amounts of time, listening to bad Muzak.  Nine times out of ten, the company refuses to grant approval for the study and requires a “peer to peer” review.  This means that I get the chart back and call the insurance company.  Now it’s my turn to sit on hold listening to an instrumental version of  “Born in the USA” while I could be actually seeing patients.  When someone finally picks up, I tell them why I’m calling.  Invariably the person that I’m supposed to speak to is on a Very Important Call, doubtless wasting some other hapless doctor’s time.  So, I give them my number to call me back.  Anywhere between 20 minutes and five days later, they will return my call.  Without a doubt, this call will come while I am performing a gynecological exam on a patient.  I will be interrupted from this and have to leave my poor, chilly patient to take the call.  The call usually goes like this:

Me:  Hi, this is Dr. Nicholas.  I’m trying to get approval for XYZ study.  The indication is blah, blah, blah.

Dr. SellOut:  OK, the study is approved.  The authorization number is 123456789.

Me:  Wait, I didn’t tell you anything that wasn’t on the order and in my note in the first place!  Why did I have to talk to you at all????

Dr. SellOut:  Have a nice day!

So, the study is approved.  Wonderful.  My staff member schedules the appointment and informs the patient.  I get a confirmation of the approval via fax, such as this:

It says “The request for an Abdominal and Pelvis CT has been approved.  It is in effect from January 23 to Feb 22, 2012.”  Note that the letter is dated January 24.

So, all done.  Everyone should be happy, right?  The patient got the CT scan on January 23.  On January 25, we get the following fax:

In case you can’t read it:  “This letter is to notify you that the retrospective request for coverage for this service is denied, and therefore, HPHC will not be responsible for payment for this service.  Reason for denial- Administratively denied for failure to comply with prior notification /consultation requirements.  Provider is liable. There is no member liability for services received.”

Nice, huh?  Translation:  “We approved this but have now changed our mind.  There is no good reason for this, we just felt like it.  You want to get paid for the service you provided?  Tough tootsies.  Pleasure doing business with you!”

1 thought on “Whoops, They Did it Again!”

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