Two months ago, I shared how I received a letter in the mail from UnitedHealthcare informing my wife that they were denying partial coverage for her breast cancer surgery.
If you've never gone through the “prior approval” process, we haven't either. But we found out quickly as the news arrived just 36 hours before the scheduled surgery.
My wife had surgery and is now healthy, and the insurance situation worked out without leaving us with more debt than we expected. But in this column, I suggested that doctors warn their patients about the possibility of receiving unexpected rejection letters.
Yes, insurance companies are to blame here, as they are often competing against patients and medical professionals. But I trust my doctor to give me a preview of possible bad news rather than an insurance company.
Last month, I published a draft of an educational notice about prior authorization that doctors could give to their patients. I also asked for feedback via our weekly Your Money newsletter.
Patients cheered me on and told me harrowing stories about how I navigated the prior authorization system. Some doctors said they would act on my memo immediately.
However, many other physicians told me that the memo needed to be shorter and simpler. Finally, some patients do not read as fluently as the average newspaper subscriber. The doctors also wanted fewer comments. Finally, an attorney might prohibit a major medical organization from commenting on the insurance industry.
You're right. I think this revised version is better. Here it is.
This note is important: Your insurance company may refuse to cover the care we recommend.
We often need to inform your insurance company about the medications, tests, and procedures we suggest before they agree to pay for them. Insurers say they do this to ensure doctors are suggesting the right level of care and the most effective types of care.
This process is called “prior authorization,” and sometimes insurers deny authorization. If that happens, they'll tell us and let you know too.
Why do insurers reject applications?
Sometimes there is confusion about which codes we should use when submitting requests. In other cases, they think we are recommending too many procedures or medications, ones that are unnecessarily expensive or may not work.
We often don't understand why insurers deny our approval requests.
We do our best to keep insurers well informed about our recommendations. When they refuse to pay something, we don't always know why.
We often cannot predict when they will object, so we will not discuss the possibility of rejection at your initial appointments.
In the event of a cancellation, we will help you.
If you hear from the insurance company that seems to be saying “no” to something, call us and let us know. We may appeal these denials, and it may be best for us to do so rather than for you.
Please help us help you.
If we have a problem with your insurer and you have a human resources specialist at your employer, that person may be able to help us expedite our appeal.
You can also call an insurance company yourself. Patients can sometimes get better information more quickly than we can, simply because we may be trying to help hundreds of patients at the same time.
How do appeals work?
We may need to speak with a doctor who works for the insurance company to explain our treatment recommendations. We will not charge you any money directly for this, although the time we spend on these appeals will ultimately be reflected in the fees we generally charge.
Because these calls are time-consuming, it may take several days for us to receive your call.
Make sure your insurance company can reach you.
Check your paper mail every day in case a rejection arrives. Get your insurance company's app and sign up for alerts. Also turn on email notifications and check your spam.
You may hear from the insurance company before we do.
Like you, we want this system to work better, and we're just as frustrated as you are.
We wish things were different and you could speak to your employer or elected officials with your own recommendations. But the best thing we can do now is make sure you aren't surprised if there is a problem. We can often get the insurance company to change their decision and pay for the care you need.