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LPT: If your doctor firmly believes that you require X treatment/medication/etc. Have them use the specific term "medically necessary". If your insurer kicks it back with that phrasing attached, contact them. Ask for the medical license number of the doctor who indicated that it was not medically necessary. Push for this information (they won't have it) and continue the line of "Someone on your end is making a medical decision against my doctors orders. I require their credentials so I can confirm they are a) qualified to make medical decisions, and b) have a higher education that my doctor possesses."
I'll be interested if someone actually tried this
I speak from experience. Blue Cross has not argued or denied any of our doctors' requests since the second time I used that method.
Had a specialist tell my wife she needed a shoulder replacement. Insurance wanted her to do physical therapy. I was livid. "I want the license number of the doctor on your end who is deciding that physical therapy is going to some how magically fix torn rotator cuff tendons. Telling our medical specialist that physical therapy is required is a medical decision that contradicts their diagnosis that it needs replaced. If we follow your recommendation and it fails, I need the name and license number of who to go after for making that decision. Shielding this professional, and I use that term loosely, indicates that you're willing to assume all the liability when "physical therapy" causes more pain and damage."
Did they ever give you a license number, or did they just cave?
Said they'd have to "look into it". Called back 20 minutes later to inform that they decided to approve the procedure.
It's nonsense. For one, what is required for a treatment is handled by CMS and the CPT code itself, so the necessary documentation is either there or it isn't and adding "medically necessary" doesn't change a damn thing. Secondly, the commercial payors go by their own schedules for what is always, is never, and can be "medically necessary," "experimental," "diagnostic-only," and a ton more. If your orthopedic surgeon is calling for a prior auth for a total knee replacement, it's always medically necessary; peripheral vein ablation, it's sometimes medically necessary; chin implant, never necessary.
Then I'm full of shit and my wife's reverse shoulder joint is a figment of our collective imaginations.
"medically necessary" I think is just one of the descriptive words surrounding the language of the laws and forms. Its actually one of a number of phrases that should work as I'm pretty sure I've had a couple without it. Realistically any challenge that requires the insurance company to actually get a doctor to review a case should get a successful prior auth.
It's not one or the other. You're full of shit and your wife would have gotten her reverse total joint surgery regardless.
Insurers are known to automatically deny procedures based on what is essentially a flow chart (illegal) rather than a medical professional review of the case (required by law). This is why most insurers back down when a prior authorization is requested.
The whole process is being abused by insurers and if you ask doctors, nurses, pharmacists they'll tell you the process is being abused.
Cigna got caught doing it https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims I guarantee you that most other insurance companies are doing this as well.
Insurance companies are going to do anything they can to reduce loss ratio, but... That is literally the plot of a John Grisham novel (pre-ACA, so it was a little more complicated than that, but still).
Maybe that's not the model that real-life insurers should be copying.
No one is saying insurers aren't horrible people and organizations denying care to patients in need. What I am saying is that "medically necessary" aren't magical words. This is some cargo cult nonsense.
You literally say it in your own reply. "Sometimes medically necessary". If you think nearly everything isn't classified as that by a company who makes more money the more healthcare they don't cover I don't know what anyone can say to you to bring you back to the reality of US healthcare. They hire unemployable doctors with histories of malpractice to deny claims in bulk.
Did you read my reply? You're really out of your depth here, buddy.
I did. It was truly unfortunate. After working in healthcare for a decade I thought i had seen all possible shit takes...I was wrong lol.
It isn't about what's actually medically necessary. Insurance companies will use any excuse to pull bs. It greatly matters how a court would view it. People are stupid and could buy the insurance companies arguments that it wasn't made clear that it was medically necessary. Its also important that scheduled procedures are generally termed "elective" even if they are something like a necessary heart procedure. That terminology could be confusing to people who are not medically literate. Making it harder to make a case against them should something happen. They know this and fuck around. CPT codes only tell them what the condition is. There are some conditions that are not life threatening but still God awful to deal with having. You better believe they try to make people try treatments their doctor already knows won't work and otherwise try to find excuses for why its not medically necessary.
It doesn't matter that you don't think such language should be necessary. This is the real world. Not some fantasy land in your head. Our Supreme Court is clearly incapable of reading the constitution. Why on earth would you think anybody else in this country would be able to read? Especially when they already have policies to intentionally hassle people because it saves them money. Its obvious you've never interacted extensively with the American Healthcare system or have only used it with Medicare. Preauths are one of the worst things I have to deal with at my job.
This reads like a summary of a chapter in a dystopian novel
It reads like sovereign citizen advice.
Ffs, is this truly where we are at? Fuck me...
Nurses usually make these calls, as I understand.