Can they do that?

[Chaoster]

My insurance plan requires pre-authorization for CT scans and MRI's. Well the doctor ordered one for my wife. The receptionist call the ins. and gets an authorization number. My wife make an appointment for an MRI. Two days after she gets the MRI we get a letter in the mail stating the MRI is not medically necessary and is denied coverage. But we already got an authorization number already, can they deny payment? I think MRI's are very expensive.

 

[NYCDiane]

Yikes!!! I wouldn't go in for the MRI if they sent a letter like that. Looks like you got a "temporary" authorization code and, after reviewing it, they deemed it "not medically necessary". If she goes in for it, you are going to be responsible for the bill.

Appeal it to the insurance company and let the docs office know as well so they can resubmit it or call on your wife's behalf.

 

[vicki_c]

The OP's issue is that his wife already had the MRI based on the authorization given.

 

[Shelly F - Ohio]

Yikes I would call the Dr office and explain to them what happened. They have the proof of who gave the pre authorization code.

I always always always call my insurance company to verify that I was approved for a procedure before I have the procedure done. I don't want to rely on the fact that the doctors office got the go ahead. I want to hear it for myself and document who I spoke to at the insurance company.

 

[jmartinez1895]

In most cases like that your doctor can write a letter ofmedical need and send it to the company. They do this all the time so just call the office and tell them what has happened.

 

[NYCDiane]

The OP's issue is that his wife already had the MRI based on the authorization given.

I think he said she made the appointment, not that she had the MRI already.

 

[disneyfreakk]

My insurance plan requires pre-authorization for CT scans and MRI's. Well the doctor ordered one for my wife. The receptionist call the ins. and gets an authorization number. My wife make an appointment for an MRI. Two days after she gets the MRI we get a letter in the mail stating the MRI is not medically necessary and is denied coverage. But we already got an authorization number already, can they deny payment? I think MRI's are very expensive.

She already had it done.

Sorry OP, I hope you get things fixed with the insurance co.

 

[DawnM]

I hope you can get this worked out. Often I find doctors' offices and insurance don't communicate well, but many times, after a lot of stress, it works out after all is said and done.

I just spent 3 months calling the doctor, calling insurance, and over and over again the same.....in my case the doctor saying I didn't have coverage and insurance saying they never received the claim.....

Dawn

 

[TaraPA]

I worked for an insurance comapny for 13 years. The pre-auth in no way authorizes approval of the payment for the service, just that the actual service - if meeting all other requirements (ex: medical necessity in this case) is able to be considered. They gave the doctor a disclaimer when they called for pre-auth - I have it memorized in my head & haven't even worked for the insurance company for over 10 years: "This authorization in no way guarantees payment of benefits. Benefits are payable upon satisfactory receipt of proof of loss & in accordance with the certificate of insurance."

It's frustrating - many doctors offices don't care enough to let you know - most people assume the pre-auth means pre-auth of payment. It actually happened to us last year with $400 of blood work for my son. We had the pre-auth but it was denied as "experimental, not medically necessary." I got all his medical records & a note from the doctor to send in, and they reversed the decision & paid.

OP get the doctor to write a note stating the diagnosis & why it was medically necessary and appeal the claim. That should be all it takes to get this cleared up. Good luck - I know how frustrating this is!

 

[disprincessatheart]

Have the dr office deal with it. I had approvals done last fall for vericose vein surgery. Waited until the full medical authorization was done and then they did the two procedures. After each one, the insurance sent a letter that the procedure was not approved. Dr's office made a few calls and it was taken care of. I definitely think in some cases they deny hoping you will just pay!

 

[Kay1]

Something similar happened to me with a dentist. I received the letter after they'd done the crowns and they went ahead and paid anyway.

 

[solotraveler]

I worked for an insurance comapny for 13 years. The pre-auth in no way authorizes approval of the payment for the service, just that the actual service - if meeting all other requirements (ex: medical necessity in this case) is able to be considered. They gave the doctor a disclaimer when they called for pre-auth - I have it memorized in my head & haven't even worked for the insurance company for over 10 years: "This authorization in no way guarantees payment of benefits. Benefits are payable upon satisfactory receipt of proof of loss & in accordance with the certificate of insurance."

It's frustrating - many doctors offices don't care enough to let you know - most people assume the pre-auth means pre-auth of payment. It actually happened to us last year with $400 of blood work for my son. We had the pre-auth but it was denied as "experimental, not medically necessary." I got all his medical records & a note from the doctor to send in, and they reversed the decision & paid.

OP get the doctor to write a note stating the diagnosis & why it was medically necessary and appeal the claim. That should be all it takes to get this cleared up. Good luck - I know how frustrating this is!

This. Your doctor will have to go to bat for you and hopefully it will work out. In future, I would double check with the insurance company to make sure the authorization is on file yourself before having the procedure. Sometimes offices will initiate the PA process, but the process may require additional records for review. With MRIs, many times the insurance will want to see documentation before approval. What may have happened here is that the doctor's office started the process, got a case number, and then the insurance denied after reviewing the documentation.

 

[dustysky]

This letter should not have even been sent to you. Yes they will try to deny payment (I deal with insurance companies m-f) but if your doctors office has a billing department that is worth anything they WILL get this paid for with that auth #.
I hate that insurance companies make it so hard.
I also hate that people have posted here that those of us in the doctors office dont care enough to tell you the FACTS, that is simply not true. Way to often we (the office staff) end up on the phone with someone at the insurance company who has NO idea what they are talking about.
I have to call BCBS more then once more often then not just to get a clear answer about a patients benefits and eligibility.
SOME of us do try and care, the last thing I want is a patient coming in screaming at me waving around a huge bill they shouldn't have gotten.
Anyways, the auth number is as good as gold if the person billing knows what they are doing. You really shouldn't be bothered with any of that, let them do it for you.

 

[Chaoster]

Thanks for the reply's. I'll see what the Doctor can do. I am just worried because we have had a lot of doctors visits, lab work, CT scans and MRI's. I hope they can't cancel my policy. It seems to be harder for them to pay for all the different tests and lab work.