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In the United States, nearly all medical procedures other than a visit with a primary care doctor require preauthorization by the the insurance company, or else the patient has to pay their cost in full. Here's what your doctor has to go to get it.

No matter how much you trust your doctor, your health insurance company almost certainly requires most procedures, all devices, many medications, and all referrals to specialists to be preauthorized. Also known as precertification or prior approval, preauthorization before your receive the drug, device, or medical service is a must, or you will be expected to pay the entire cost out of your own pocket, unless you are receiving the treatment in a medical emergency. Even when your doctor obtains preauthorization, however, the insurance company does not guarantee to pay. What your doctor has to do to get preauthorization is daunting, and what can happen to you if you don't can be horrifying. Here are some documented examples.

  • The Enterprise-Record (Butte, Montana) reported the story of a 27-year-old man who obtained preauthorization for a heart transplant, but the insurance company would only pay for four days in the hospital. The insurance company also refused to pay for new bandages when his surgical incision site became infected. The young man died.
  • A mother in Atlanta, Georgia called her HMO at 3:30 in the morning to speak with advice nurse because her six-month-old baby boy had a 104 degree F (40 degree C) fever and was limp. The nurse insisted that the mother take her child to the nearest hospital which was "in plan" for her insurance coverage, 42 miles (65 km) away. By the time the mother reached the hospital, her baby's meningitis had progressed to the point that it was necessary to amputate his legs and hands.
  • The Washington Post reported the case of a Washington, DC woman who complained of a sore throat and nausea a week after having stomach surgery. Her HMO sent her to a relatively inexperienced doctor who told her to go home and get more rest. She died of complications of a puncture to her esophagus during the surgery.
  • A sixty-year-old writer for Steady Health managed to contract a disease called necrotizing fasciitis, which is caused by "flesh eating" bacteria. Getting to the hospital in plenty of time, he received the treatment he needed to save his life, but his insurance company refused to pay. The reason? The emergency room physician "failed to note that symptoms included 'giddiness,'" as if septic shock were a laughing matter. When he threatened to take the insurance company to court, they ruled that neither they nor the writer (the patient) owed the hospital any money, making it impossible for him to sue them.

American health insurance companies don't make it easy to get medical treatments paid for. Any error on the part of the physician is likely to result in the patient's having to pay the bill. When treatments are compensated, it's usually because some doctor invested a great deal of time and patience in dealing with the company's preauthorization department. Just how difficult is it for the doctor to get pre-approval? Here is a typical conversation between a real-life doctor and a real-world insurance company, modified for patient privacy.

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