Published: August 10, 2008
You are sitting in your doctor’s office. Your doctor is explaining a procedure or diagnostic test that is necessary for your care. But before you have the procedure, the provider’s office must do a “pre-cert.” What does that mean?
A pre-certification, or pre-cert, is the insurance company’s way to place themselves between you and your doctor to control their expenses. Before committing to pay for a procedure, the insurance company requires the provider to call the insurer and discuss the situation with their representative. Simple enough, right? Not exactly.
Pre-certs are increasing as insurers look for more ways to increase their profits. They have found that this simple step can reduce their costs significantly. Often implemented prior to approving diagnostic tests and expensive procedures, pre-certs can create significant delays or jeopardize proper patient care.
In some cases, a provider’s office simply calls the insurer, answers a few simple questions regarding the service ordered and the diagnosis, and authorization is given. With the exception of tying up a staff member for up to an hour while the insurer keeps them on hold, this type of pre-cert is relatively harmless.
In other cases, the insurance company refuses to make a decision without delaying hours or sometimes days “reviewing” the request. Considering that the doctor managing the case has made a decision based upon their actual contact with the patient and knowledge of the patient’s history and current condition, you might wonder what the insurance company is doing during their “review.”
In many cases, a review means an employee of the insurance company, often a nurse or sometimes someone with no medical training at all, is checking the answers given by the provider’s office against the answers shown on a computer screen as being acceptable. Some reviews will result in a denial.
What should you do if an insurance company denies a procedure for you or a family member? If it hasn’t happened to you yet, it probably will at some point.
You should know that you have rights to appeal that decision. You also have the opportunity to go ahead and have the procedure and pay for it out-of-pocket, then seek insurance reimbursement later, although this isn’t guaranteed. The insurance company isn’t saying that you can’t have the procedure, only that they don’t agree to pay for it.
You also have the option to go to another provider, perhaps a specialist, for another opinion. If two providers agree that the procedure is necessary, the insurance company has little rationale for denying it.
Then there is what I call the “squeaky wheel” approach. You may have heard the expression that “the squeaky wheel gets the grease.” That means that the person complaining the loudest usually get results.
The story of an elderly lady who came to my office many years ago illustrates this concept. She had Medicare and at the time Medicare would only approve limited services, no matter what the circumstances. But this lady was able to get Medicare to approve services beyond anything I had ever seen. I asked her how she accomplished this.
“Well,” she said, “If I get a denial I sit down with a cup of coffee about 4 every afternoon and call Medicare. Once I get a real person on the phone I begin telling them how much I hurt, how helpful this care is for me and how much I need it. I just keep repeating my story in as many ways as possible. I know they want to leave at 4:30 and they are not allowed to hang up on me. Sooner or later, someone finally gives in and approves my treatment!”
Now that’s what I call being resourceful to get results! I can tell you that this lady always got results.
If an insurer has denied you services, realize you have options. If you refuse to meekly give up and persist in trying to get the services you need, you are likely to be approved.
Next week I’ll tell you the story behind a recent headline. In the meantime, insist that your insurance company treat you fairly.
Dr. Mark Kestner
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