"The Guy" and the MRI - Part 1
A few years ago, I had results from blood tests that could indicate a problem that could require immediate action. The specialist that I was seeing ordered an MRI of the chest and abdomen. Being more afraid of my Insurance coverage than any possible outcome, I naturally called for Pre-Certification or Pre-Approval (for those that are not familiar with these terms, it is a meaningless step to go through to get you later). I was told that my call would be sufficient to start the Pre-Certification process. All decisions are to be made within 72 hours of calling for approval according to my contract.
Jumping ahead 1 week; the MRI was fine except for some things that everyone will have if they look hard enough (a good reason not to have a full body scan) and I found out that no further medical procedures were required.
Two weeks later, I received a bill for slightly under $4,000 and was told that my insurance company had determined that the test was not medically necessary.
Let me explain the structure of my insurance company. There is a person with an important title that determines the necessity of any tests that have an acronym. I don't recall what his title was, but I am pretty sure that it had the words "medical," "director," and "doctor" somewhere in it. So, I will call him "The Guy".
Evidently, The Guy was on vacation for a few weeks and no one else had access to the "denied" stamp. One thing that I would suggest to anyone wanting to start an insurance company is to have an extra "Guy" around.
So that no one thinks me to be an unreasonable person, I do not expect everything to be approved, but it doesn't seem to be too much to ask to know ahead of time if there will be a problem.
The resolution of this problem took about 2 years to finally resolve...more on that later.
TVP
Make Comment Email The Virtual Patient Twitter
Jumping ahead 1 week; the MRI was fine except for some things that everyone will have if they look hard enough (a good reason not to have a full body scan) and I found out that no further medical procedures were required.
Two weeks later, I received a bill for slightly under $4,000 and was told that my insurance company had determined that the test was not medically necessary.
Let me explain the structure of my insurance company. There is a person with an important title that determines the necessity of any tests that have an acronym. I don't recall what his title was, but I am pretty sure that it had the words "medical," "director," and "doctor" somewhere in it. So, I will call him "The Guy".
Evidently, The Guy was on vacation for a few weeks and no one else had access to the "denied" stamp. One thing that I would suggest to anyone wanting to start an insurance company is to have an extra "Guy" around.
So that no one thinks me to be an unreasonable person, I do not expect everything to be approved, but it doesn't seem to be too much to ask to know ahead of time if there will be a problem.
The resolution of this problem took about 2 years to finally resolve...more on that later.
TVP
Make Comment Email The Virtual Patient Twitter
Posted by The Virtual Patient at 2/22/2009 7:50 AM 
Categories: Pre-certification, Reasonable and Customary, Insurance, Pre-approval
Categories: Pre-certification, Reasonable and Customary, Insurance, Pre-approval
I like this concept. I visited your blog for the first time and just been your fan. Keep posting as I am gonna come to read it everyday!!
Reply to this