Get Your Medical Authorizations Approved
I'd like to share an experience with you that may help you get your procedure approved if your physician's request keeps
getting rejected. This may or may not apply specifically to you, but it does highlight an issue with many physicians that you might find useful.
Many years ago, I had to have an operation. I had a lump in my breast that was painful. I don't know where it came from, and I
never thought it was cancerous. I'd had the lump for awhile, but when it started to hurt, I knew it was time to finally see a doctor for it.
He did an evaluation, and decided that it needed to come out, just to be sure. I did have the mammogram, which, for a guy, is
painful enough, but really hurt with the lump in there. It didn't show anything one way or another, which is why it had to come out.
Strangely, my physician kept telling me that the request for the authorization was being denied by the insurance company.
He filed the request three times, and it got denied every single time. Being in healthcare, I knew something was wrong, so
I did what most people should do; I got on the phone and called the insurance company. They said that the diagnosis code
(sometimes known as ICD-9 code) indicated that it was a cosmetic procedure. I said that I was in pain, which is why I had
gone to the physician in the first place. I was then told that the physician needed to add the code for pain, and she gave
me the code to give him. I called him back, gave his staff the code, they put it on the authorization and called it back in,
and within the hour my procedure had been approved.
The problem wasn't necessarily with the code, but the extent that the physician had gone with it. Physicians aren't always
on top of things when it comes to coding because, for outpatient procedures, they just don't think about it all that much.
Sometimes it's not the physicians who are doing the coding, but their office staff, and none of them have any training beyond
the cursory things they're taught when they start working in a physician's office. Even nurses don't always know to code
more fully than they do.
As a matter of fact, if you're a Medicare patient, you have probably at least once in your life been asked to sign an
Advanced Beneficiary Notice saying that you agree to pay for a test or procedure of some sort because Medicare won't cover
it with the diagnosis code the physician sent. This is the reason; because physicians often only send one code, but ask
for multiple things, and those other items aren't covered under the original code.
Anyway, that's my story. So, if you ever find yourself having your physician's office telling you that your insurance
company didn't authorize your procedure, get on the phone and ask your insurance company what diagnosis codes are needed
so that your procedure will be covered. Be sure to ask your physician's office first what diagnosis they used to try to
get the authorization in the first place so you'll sound informed. And, when given a script by your physician for tests
or procedures, always ask them if they've made sure to add all the codes you need to get your claims paid by your insurance