Health Insurance Companies Don't Make Health Insurance Preauthorization Simple

Health maintenance organizations (HMOs) are notorious for requiring preauthorization. Even worse, they often require doctors to speak with high school-educated technicians who make the final decision on whether or not a patient gets a procedure.

In 2015, a doctor, whom we'll call Dr. Brown, needed to put in a call on a Thursday afternoon to get prior authorization for an MRI for her patient, whom we'll call Mrs. McGillicutty, the next Monday. First she tried to use the health insurance company's website. It was down. She tried again an hour later. She input all the required information and then got a 404 error message. She needed to get home to her family, but the patient needed the MRI, so she phoned the insurance company's preapproval office. Here's what happened.

Dr. Brown dials the preapproval office. After 30 seconds, the phone on the other end of the line rings and she hears a recorded message, "Thank you for calling Preauthorization. You can use our convenient website," which was not in this case true," by going to" the company's web address. "This call may monitored or recorded for quality assurance. Please press 1 to reach our preauthorization office. If you are calling for any other reason, please press 2."

Dr. Brown presses 2.

Next she hears another prerecorded message stating that emergency procedures do not require preauthorization and asks for the reason for making the call. "Radiology," Dr. Brown says to the computer. The system responds with a request for the reason referring Mrs. McGillicutty to a radiologist. "She has a giant knot on her head," Dr. Brown answers. Mrs. McGillicutty had a large growth on her skull, and Dr. Brown wanted to make sure it was not malignant.

The system then asked for the patient's name. "Please use your keypad to enter the first three letters of the patient's last name." Dr. Brown uses the numeric keypad of her phone to enter three letters, holding down keys various lengths of time to record letters. "Please enter just the first two letters from the patient's first name," the perky computer-generated voice requests. Dr. Brown complies. "Now use your keypad to enter the patient's date of birth, beginning with the month, then the day, and then the year." Dr. Brown enters the requested information. Next the system requests the patients identification numbers, but just the numbers, not any letters that the company may have assigned to the ID. Dr. Brown ignores three letters at the beginning of the patient ID and three letters at the end of the patient ID and just enters a 12-digit number. Why the system didn't just ask for the patient ID is never explained.

At this point, Dr. Brown has been on the phone for six minutes. The system next asks for the doctor's office number, starting with the area code. Of course, since nearly all phones are equipped with caller ID, the system could have simply recorded that number and asked if the doctor was calling from her office. Dr. Brown gives a number such as 555-555-1212. The system then responds with "I think you said 555-555-1212." The system does not ask for further information. Then the system says, "I'm sorry. I'm having trouble finding your information. Did you say 555-555-1212?" Dr. Brown answers "Yes." However, the system is not able to match her office number with their list of approved providers, so it instructs Dr. Brown to stay on hold.

Dr. Brown stays on hold another eleven minutes.

Finally a recorded message plays stating that it is transferring Dr. Brown to a preauthorization agent.

"Hi, I'm a preauthorization agent. My name is Dawn. How may I help you?"
"Hi, Dawn, I was needing a preauthorization."

Dawn asks for the patient's home address, which Dr. Brown gives her. She responds "I'm sorry. We don't have that address on file." Dr Brown responds, "That's unfortunate."

Two minutes later Dawn comes back on the line to announce that "If her address has changed, we can still make the preauthorization." Dawn then asks to put Dr. Brown on hold.

For another five minutes, jazz music plays in the background. Then Dawn comes back on the line to ask Dr. Brown's phone number, which could be obtained from caller ID, and which Dr. Brown had already entered.

Dawn asks for Dr. Brown's phone number two more times, and then asks if this was a number where they could call without being put on hold. Dawn asks Dr. Brown her name and how to spell it.

Another 90 seconds pass while Dawn enters the name on her screen.

Dawn then asks when the procedure is scheduled. "I believe it's scheduled on Monday," Dr. Brown answers. There is another long pause.

"May I have your office address please," Dawn asks. Dr. Brown answers. At this point, 25 minutes have passed. Another minute passes until Dawn comes back again to ask for Dr. Brown's fax number. 

Finally, Dawn asks what procedure is being ordered, and whether Dr. Brown has researched the ICD-10 billing number. Dr. Brown had the number. If she hadn't, she probably would have had to call back.

Dawn then asks the doctor to confirm a long list of symptoms to confirm the diagnosis used to choose the billing number. "Can you feel the lump in her brain?" she asks.

Of course, the probable tumor is in Mrs. McGillicutty's skull, not her brain. It would be an emergency situation if Dr. Brown could feel the tumor in her patient's brain. Having confirmed the diagnosis, Dawn then asks all the address, phone number, and fax number questions about the hospital that she had asked about the doctor's office. The doctor herself has to answer them.

Dr. Brown is put on hold yet another five minutes. But finally the preauthorization clerk comes back with a preapproval code, which doesn't guarantee the insurance company will actually pay for the procedure, but without which they certainly will not.

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It's probably tedious for you just to read about this doctor-insurer encounter. It was more tedious to watch a video of the call. It's no doubt enormously tedious for doctors who have to deal with these kinds of issues several times a day. So what can you do to cooperate with your doctor to increase your chances of getting the treatment you need paid for in a timely fashion?

• Make absolutely sure that your doctor's office has your current insurance information.
• Make absolutely sure that your doctor's office has your correct address and telephone number.
• When you get a referral to a specialist, keep your appointments. You may not be able to get a second referral.
• Expect "issues" when it comes time for your insurance company to pay. Be sure to keep copies of any and all approvals you get for doctor visits and medical procedures.

If you are insured by an HMO in the USA, you may spend almost as much effort keeping up with billing as you spend getting well. There is a way around this. Whenever possible, sign up for PPO (preferred provider organization) coverage rather than HMO (health maintenance organization) coverage. The premiums cost a little more, but it only takes one procedure a year to make up the difference.