medical procedure scheduled before insurance approves it, what to do?

January 1, 2020 6:30 PM

Just got a letter from the insurance company asking for additional documentation on a medical procedure I'm scheduled to receive tomorrow. Sounds like the insurance neither denies nor approves the procedure, but wants additional information to make that decision. Am I correct in assuming that I need to refuse the procedure tomorrow and get rescheduled after insurance has approved?

My current plan is,

1. Email my doctor a scan of the letter from the insurance company, and ask him to provide whatever documentation the insurance company requests.

2. Call the provider tomorrow to cancel my appointment and ask if they will reschedule me speculatively for some later date, on the assumption that the insurance company will eventually approve the procedure.

Is there anything else I should do?

Additional complication: As per usual for me, there was a medical records error where someone in the doctor's office sent the provider a prescription with the wrong name and the wrong procedure. The provider caught the error when I showed up for my appointment expecting a different procedure, and re-scheduled me for the correct procedure. It didn't occur to me to ask at the time, but it's possible that the insurance company also has the incorrect prescription.

I am in the U.S. (of course).

posted by meaty shoe puppet to Health & Fitness (7 answers total)

If insurance eventually denies the procedure, will you do it anyway and pay out of pocket? If so, I might just go ahead and do it tomorrow, depending on urgency and difficulty of rescheduling. If not, then definitely reschedule.
posted by brainmouse at 7:18 PM on January 1, 2020 [2 favorites]

I would call the insurance company first thing and make them tell you what their problem is and if you should go through with the procedure or not. Then call the drs office if you do need more documentation or you need to reschedule.
posted by bleep at 8:35 PM on January 1, 2020 [2 favorites]

Rather than dealing with your insurer, I recommend that you call your doctor’s office. Don’t email, call. There is definitely someone at that practice whose job it is to complete insurance prior approval paperwork. It might be that the holidays and people on PTO have led to some bureaucratic snafu, but chances are good the designated employee at your doctor’s office can fix this quickly enough for you to carry on with your procedure tomorrow.

Don’t bother calling your insurer. And don’t cancel anything unless your doctor’s office says they can’t get the prior authorization completed in time-in which case they should offer to reschedule you themselves.
posted by little mouth at 7:35 AM on January 2, 2020 [4 favorites]

In my long experience the doctors office has even less of a clue what's going on than me and no ability or desire to find out. The only person who knows if this is happening or not and why is the insurance company.
posted by bleep at 11:02 AM on January 2, 2020 [1 favorite]

I used to work as a CSR for a big insurance company. I'd recommend calling the doctor's office and here's why--they want to get paid. The insurance company doesn't want to pay for your surgery. Institutionally, you're more likely to have a better outcome going through the doctor. Does that mean the person at the doctor's office is guaranteed to know what they're doing? Not necessarily, but if you call insurance, you may or may not even be able to get through to the right department to tell you what additional information is needed, and if you do, you most likely aren't going to be able to provide the information yourself. Chances are they need additional medical records, and I'm assuming you don't have copies of your full chart.
posted by zeusianfog at 2:03 PM on January 2, 2020

And the insurance company isn't going to be able to give you useful advice about if you should proceed with the surgery.
posted by zeusianfog at 2:03 PM on January 2, 2020

Response by poster: My doctor decided to go away for a long vacation, so I got an appointment with another doctor in the office to repeat the examination and re-prescribe the procedure.

Then the insurance company approved the original prescription, but as incorrectly reported to them by whoever screwed up my paperwork. Because I had been approved for the incorrect procedure, the insurance company didn't want to approve the correct procedure.

Then the insurance wrangler in that office suggested I just go ahead and have the incorrect procedure, since it was similar. (?!!!)

I managed to convince the insurance wrangler I should have the procedure both doctors prescribed, rather than another procedure that some paper-pusher accidentally picked in a form somewhere. To his credit, he then convinced the insurance company to approve the correct procedure, and recommended I double-check with the provider.

Indeed, it turned out some other bit of the prescription had been lost between the doctor's office and the provider, s.t. the provider once again had not secured the equipment needed to perform my procedure as prescribed.

So now after three extra days off from work, an extra co-pay, and a month, I am approved and scheduled for the correct procedure. We think.
posted by meaty shoe puppet at 9:29 PM on January 7, 2020 [1 favorite]