YSK: There is a process your health insurance company set up called "prior authorization" used to weasel out of paying for medical services your doctor decided are medically necessary like MRI and CT exams
If your doctor says you need an MRI or CT or something they give you a referral and send you out the door. Sometimes with a facility in mind, sometimes for you to find a place you want to go on your own. You call a place, you ask if they are in network. They say yes. You call your insuance to confirm that facility is in your network. They say yes. Good to go yeah?
You go in, you pay your copay or coinsurance, get your scan, walk out with a disc for your doctor. You schedule Your followup to discuss the results.
Two weeks or two months later you get a bill in the mail. Its for another $200 or so bucks for the MRI. How could this be? You have insurance and they are in your network?!
Well you see, while your doctor (a trained and licensed medical professional) decided that it was in your best interest and important in the process of treating you that you have this exam, your insurance company doesn't immediately agree. Most insurances have implemented a system called 'prior-authorization' for exams such as this. Essentially being in network isn't enough for them to pay for the services your doctor deemed necessary for your health. You need to now pass their 'Medical necessity evaluation' to use your benefits for these exams.
They created their own criteria (off the top of their heads, there may have been some physician input but these are all arbitrary made up corporate rules) and they want someone from either your referring doctors office, your primary care providers office, or the facility itself, to contact them and answer a bunch of questions to see if their arbitrary criteria is met. You can often submit everything in your entire chart and have your request for approval pended for days, weeks, or sometimes months. At the end of this process your insurance company can pick any part of their criteria not met and deny your exam (which means your benefits will not apply and your exam will be deemed 'not medically necessary' and therefore you would need to self pay for the procedure as if it were elective)
It does not matter if you are bleeding from your anus and doubled over in pain, your insurance never recieved the request as urgent so you need to wait 2-14 business days while the request is processed. Oh they also never recieved your white blood cell count or the report of an ultrasound or some other ridiculous thing they don't really need and that may not even exist to provide (maybe your doctor decided it was in your best interest to skip straight to a CT instead of doing an ultrasound or some other exam first, too bad corporate profit supersedes your doctors judgement)
This is seldom, if ever, communicated to patients by their doctors or their insurance companies. You often have no idea that if some high school graduate admin staff in the back of the office doesnt file a fax request for your procedure prior to you receiving the service that you will be stuck for the full amount. And that often this process takes days or weeks making same-day care impossible (sorry boss gonna have to take off another day next week pls dont fire me)
you have no idea what those criteria are for each exam and often your doctors office doesnt either. You could very well pay for a doctors appointment, receive an order for an MRI of your ankle because your doctor suspects a tendon or ligament injury, wait for two weeks with no phone call to schedule the MRI appointment, call in and find out your insurance won't approve it without an xray to rule out a fracture that your doctor already believes you don't have. (and would also show on the original exam) Make a new appointment, pay another copay, get a new order for the xray, take off time from work, get the xray only for it to be negative and prove your doctor knew what they were talking about because that's what theyve been doing for 20 years of their life, then have them refile for the MRI approval, take more time off work, then finally have the MRI and make your third follow up and pay another copay.
This practice hinders expedient patient care on a massive scale and creates nothing but unnecessary human suffering for profit. The practice of prior authorization will be argued by the health plans as a cost saving measure for the benefit of consumers but in reality it is just an arbitrary system of hoops set up with the knowledge that a percentage of patient will fail to jump through them, therefore the company can avoid paying those healthcare costs and post a higher profit margin. A comparable practice is when a company like Comcast 'erroneously' charges millions of customers an extra fee knowing that there is a large nonzero percentage of people that do not have the time or energy or ability to fight the charge, converting every failure to address the issue into profit.
I have seen long time cancer patients have their PET scans denied. I have had insuance companies make elderly arthritis patients wait for weeks only to kick the request back because the corporate logo on the form wasn't that company's most recent iteration (on an otherwise completely identical form). I have seen patients get MRIs approved only to learn they have metal in their body that could literally kill them if they got in the machine, but the insurance company will refuse to approve the CT because they 'don't have a guideline in the system for that'. I have seen patients forced to wait 90 days after hurricane Irma to get a new approval because they didnt get in before their approval expired and the insurance says 'sorry the rules are no extensions' but they made those rules up and theres no law that states it needs to be that way.
Be aware of this practice and don't let it happen to you. Stay on top of your doctors office staff, and stay on top of your insurance company. They have set up an intricate web of tricks to make the process just difficult for just enough people that they can convert those unpaid healthcare costs into pure profit.
Teach others about this and get everone you know on the lookout. The only way this ends is if it stops being profitable. If everyone knows then it ceases to work as well, and hopefully one day the expense of paying the wall of employees to weasel out of fiscal responsibility to patients will overcome the savings of not paying for peoples treatments and maybe the companies can be convinced to stop this.
TLDR; Always ask your insurance if your procedure requires a prior authorization before having it performed!
