What do you do if your insurance company denies a procedure?

[Neurotica]

I'm so worried. We haven't been "denied" yet, but the physician in charge of pre-authorizations is refusing to give us a pre-authorization until he receives more paperwork from our doctor. I haven't talked to insurance yet because I learned about this (from our doctor's office) after hours.

Meanwhile, my son was supposed to get MRIs tomorrow night. Now we have to cancel. Everything therefore gets pushed to the right, including diagnosis and treatment. The concern is cancer or another disease. Extremely scary and stressful time and now we have more waiting to do.

[Telly Savalas]

1. I think most insurance companies typcially have internal appeals processes

and if that doesn't work you can contact your state's department of insurance if you think you're being given the run-around. If neither of those avenues get you anywhere, contact the local media. The threat of bad publicity can possibly steer the insurance company towards appropriate behavior.

And in every step of the way, be assertive and hold your ground but be polite and non-combative. This will marginally enhance the chances you can get what you need.

[Neurotica]

4. Thanks for those pointers

I hope we don't have to go through an internal appeals process. There is no time in a situation like this. Ultimately, I think we will end up having to do a biopsy and this delay impacts the timing of that procedure as well.

That's a good idea about the state's department of insurance.

Regarding publicity, I was already contemplating how I was going to put my corporate communications experience to work if necessary...

Thanks as well for the reminder about being polite. It's probably a good thing I learned about this after hours. I'm already much calmer than I was an hour or so ago.

[Curmudgeoness]

2. Your doctor is your best advocate. And he/she has been here before.

It is not uncommon to delay or deny authorizations, but the doctor should be willing to go to bat for you, and for his/her decision that this is necessary. Start there.

[Neurotica]

3. They have been really helpful, and I think they will do whatever it takes

Our doctor's secretary, who left me the voicemail about the delay, was quite upset herself and called the situation ridiculous. This is a huge orthopedic practice accustomed to dealing with insurance requirements so I am anxious to talk to her and hear more about what happened.

In the voicemail she did say that they are compiling all the necessary info and the insurance physician should have everything by tomorrow. Unfortunately, that doesn't allow us to keep all the appointments that we have set up.

[Curmudgeoness]

5. Cost containment, ain't it great! I do hope all turns out well

in the end. Don't give up.

[Neurotica]

6. Thank you.

I was relaying all of this to my husband and he was too nice in his assessment of the situation. He said that maybe the insurance company (one of the biggest) doesn't have all the info they need. I said, yea right. This is a tactic to increase profits. I remain highly skeptical. And I would like to know how the insurance physician somewhere else in the US has a better understanding of the things going on in my son's legs than the orthopedist who is treating him!

And, btw, the orthopedist is not willy nilly ordering tests. Certain imaging tests were already performed, and the results led to the necessity for further imaging tests. I think the orthopedist has already been quite judicious in his use of medical procedures; if only the insurance company would recognize this...

[Curmudgeoness]

9. It isn't a done deal yet, don't get too worked up yet.

Save that for when you need it. You are right, there is no way that an "insurance physician somewhere" can know more that your son's doctor. My sister is an RN and worked for about a month for a super-huge insurance company where she took calls to authorize procedures. She could not live with it and figured she would be fired soon, since it was routine to deny first, and she said that without knowing enough about the case and patient, it was impossible to know whether the decision was right or wrong. So she quit. And this was at least 20 years ago, I am sure that they are worse now.

Just remember that, it was "routine" to deny at first. You would not believe the number of people who stop there.

[Neurotica]

11. I was telling my husband about an exact situation like your sister's.

I remember watching an expose on TV -- maybe it was 60 Minutes a long time ago. The person being interviewed couldn't take it anymore and was willing to spill the beans on routine denials. I feel for your sister and hope that she's happy wherever she's working now.

You're right about getting worked up. I was beside myself for an hour, but I'm in a much better state now. It was very hard to tell my son, though. He was really upset about the delay.

[blondeatlast]

12. I was turned down for an 80K procedure--my extremely wonderful PC

spent an entire day haggling with the insurance people--and won.

[Curmudgeoness]

13. Kudos to all the wonderful dedicated doctors out there! nt

[blondeatlast]

14. She's awesome, I wouldn't be here today if she hadn't done that. nt

[Neurotica]

16. Wow. Your doctor is amazing!

It's so reassuring when you have that kind of partnership with your physician.

[riderinthestorm]

7. You might just be in the middle of the upcoming holiday shuffle

Try to breathe. Your doctor just has to send over more paperwork for the pre-authorization to occur but a lot of doctors are already winding up for the long weekend. Especially if your doc is taking time off, he's doing what everyone does before they take time off work: clearing up loose ends, doing last minute things etc. It's possible that paperwork is still there waiting for him to do (or he left already and just simply forgot about it. Easy to do when one is leaving for a long weekend).

Your son's doctor will be his first advocate and you need to give him the chance to get this done for your son. After that if you get a denial, you will have to go through the internal appeals board but there again your doctor will be your strongest "voice". Keep him/or her on your side.

I am so sorry about this for you all. It's so frightening when you just don't know what it is.

[Canuckistanian]

8. Why can't insurance companies be sued?

Is it illegal to sue them?

[tavalon]

10. No it isn't illegal and they even factor that in to their bottom line

Sick, huh? Death Panels? We got 'em right now under the names Premera, Heritage, Aetna, Etc.

[Canuckistanian]

15. Yes, but...

In a normal world, you could easily prove in court that an insurance company is doing ACTUAL HARM to human life by denying claims, limiting coverage, etc, etc.

Why can't they be sued? What's stopping anyone from bringing a suit?

Forgive me, I'm just a simple Canadian who knows next to nothing about these fabled "health insurance companies"