Preauthorization Hell: What Your Doctor Has to Go Through to Get Your Insurance to Pay

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.

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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.

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.