I had never had an MRI before, but I have seen them being done. Spending an hour in a loud banging dark tube wasn’t something I was particularly excited about. Nonetheless, I figured it was worth doing.
I get the MRI and aside from some incidental findings of unknown significance (don’t you just love those?) it was normal. Thankfully. Before I got the test done, I called my insurance company as I knew the test would be expensive and I wanted to make sure I didn’t have to get any sort of pre-authorization. I called and the pleasant woman told me that with my plan, I don’t need any pre-authorization. I went about getting my test and enjoying my results and incidental finding.
About a month later, I get a letter from the hospital where I got the test saying my insurance company informed them I didn’t follow the proper pre-authorization process and I was responsible to pay the nearly $4000 charge. In a panic I called my insurance company and the pleasant lady (different from the first pleasant woman) told me that the hospital is wrong as it is their responsibility to have properly submitted the claim. I was told that I didn’t need to do anything further at this time, but I was given the claim number to report to the hospital if they continue to ask for payment, along with the information needed to tell the hospital regarding my non-obligation to pay at this time.
I called the hospital and spoke to another pleasant woman in billing who understood my situation and she marked my file to make sure they would properly submit the information and confirmed that I did not need to pay anything.
Fast forward several months and I get an explanation of benefits statement from my insurance saying that I am responsible for the entire almost $4000 charge because I did not follow the proper pre-authorization process. While I am a doctor, I am divorced with multiple little F’ers to support and don’t have $4000 to spare.
I again called my insurance company – this time on a weekend. I spoke to another pleasant woman who explained that I could appeal the decision and in the appeal I should mention that I called in advance and was told that I didn’t need to get pre-authorization. I asked if Crappy Insurance Company had notated my file when I called in advance last year. She said they do keep a record of all calls but the weekend computer system does not provide her with access. She told me I should appeal whether they had a record of my call or not. I of course figure my appeal would be stronger if I point out the date I called and to whom I spoke. I asked the woman I was speaking to why I would have been told that I did not have to do any pre-authorization if I actually am. Rather than tell me what I expected which was that I was told wrong information, she instead explained that my policy does not require pre-authorization, as long as the test is medically necessary. Medical necessity is based on the doctor’s clinical notes sent AFTER the test is done. Hmmm. Perhaps I’m a bit demented, but this seems like a recipe for disaster.
On Monday, I call back and speak to a less than pleasant woman. I ask for the date of the call I made before the test and to whom I spoke that told me I did not need pre-authorization at that time. She said that she can’t give me that information. I start to get a bit upset (and I almost never get upset) and explained my shock that I go through the effort to call in advance and am told there was no need; I’m then told that my claim is denied; I’m then told I should have gotten pre-authorization as they determined it wasn’t medically necessary; and then I’m told that they have a record of when I called but they won’t release that information. I asked her as well about pre-authorization being required and she (unlike the prior two pleasant ladies) tells me that I should have gotten prior authorization and the first lady gave me wrong information in saying it wasn’t needed. This less than pleasant lady said I should still appeal and tell them I was given wrong information. She also said I should have my doctor appeal as he may be able to provide more information to substantiate the medical necessity of the claim. I told her that he had already sent in my information.
She types for a minute and says that she sees that information was received but it isn’t clear if the reviewers actually read the clinical information before denying the claim. She said that she would resubmit my claim to have the clinical material reviewed and I should hear back in 15 business days.
I actually get a call back from the insurance company a week later (yesterday). They tell me the claim was reviewed including the clinical information and my claim is still denied. I asked what I should do next as this is getting ridiculous and I don’t want to get stuck paying $4000 out of pocket because of some process that I don’t understand and that seems so completely wrong. She tells me that I don’t need to do anything as it was the hospital that did not follow the proper pre-authorization process and so they need to do the appeal if they appeal the decision. She tells me that I don’t have to pay anything at this time.
I tried to call the hospital to explain what I was told but I sat on hold for over 30 minutes and decided to try another time. This whole process is ridiculous. Why couldn’t they have just told me to get pre-authorization and this whole thing would have been avoided? I don’t understand this policy of doing pre-authorization / medical necessity determination after-the-fact. It doesn’t benefit anyone in a situation where it is a non-emergency MRI. Either way we’d have to show medical necessity – it may as well get done before the exam.