What if your health insurance doesn't approve something you have already done?

[Wade Lippman]

I went to the internist Tuesday. He sent me to have CT. They took my insurance and charged me a $35 copay.
Wednesday the insurance company called to tell me I had approval to get a CT. I thanked her.

But what if they didn't approve it? I know I can appeal that it was medically necessary, but my wife (a NP) thought they should have just done an xray, so it is hardly certain I would have gotten approval. Would I be on the hook for it, the CT center who took my insurance, or the physician who scheduled it before I could possibly gotten approval?

Or do the physician and CT center know it is always approved, so there is never an issue?

I couldn't find a health insurance forum to post to :) but figured someone here is probably in the business or has had the experience.

[roger wiegand]

If your doctor's office is competent and well staffed they will typically get a required pre-approval for you. However, it always pays to check as you can stuck with a bill, not at the rate the insurance company pays, but at the special "sucker" rate for people who pay directly. (Typically 3-10X more). Also beware, especially with imaging procedures, of using one that is "in network" rather than "out of network". The one in your Doc's office or in her building may not be "in network" for your insurance. The co-pay difference can be substantial. Generally you can get imaging down anywhere, not just where your doc sends you by default.

[Matt Meiser]

I had a diagnostic test earlier this year that was initially not approved. Doctors office went through some process where they appealed it and got it approved after a phone conference between my doctor and some kind of medical professional on the insurance company's staff. The nurse at my doctors office said at one point not to worry because basically if the doctor has sound reasoning for wanting the test, it will get approved--sometimes it just takes extra work on their part.

[Wade Lippman]

Also beware, especially with imaging procedures, of using one that is "in network" rather than "out of network".

I did not check that, but if they took my insurance and charged me the correct copay, would that mean they are "in network".

Yes, I would have expected the physician's office to get pre-approval. Does the insurance company calling me the next day mean they didn't, or is that just confirmation of the pre-approval?

[James Gunning]

Be very careful about expensive diagnostic procedures ordered by any health care professional. Double and triple check that insurance will pay for it. My wife has had several problems that have required medical treatment. At one point a test (I recall it was a CT scan-but not positive without looking it up) was ordered and performed. The insurance company (well after the fact) refused to pay for it. It all hinged on how the diagnosis was considered. Short story is, we were stuck with a multi-thousand dollar bill (at the sucker rate-not the insurance rate). I talked with the facility billing us and basically pleaded with them to help us out. They took mercy on us and gave us something like the insurance rate, which helped enormously, but we were still on the hook for several thousand dollars. I worked out a payment plan and was paying the bill off monthly. After about a year, praise God, the insurance company out of the blue decided to pay the balance of the bill.

Lesson learned, now we ask if they want to prescribe an aspirin. As time goes forward, I only forsee the health care system getting worse and worse. The times when we could count on insurance generally paying for what ever was medically needed are gone.

[Jim Koepke]

The times when we could count on insurance generally paying for what ever was medically needed are gone.

I do not recall there ever being such a time. I have had insurance through a major national company that would automatically reject every claim. Each claim had to be resubmitted with a new form which was about 10 pages. It was the worst insurance of my life.

My current situation is with the provider we have had for years but transitioning in to medicare. I expect some bumps along the way.

jtk