How do navigate insurance with hospital staff?
December 8, 2015 11:10 PM Subscribe
I need to get an MRI and my insurance wants my doctor's office to send them a notification, otherwise I'll be subject to a financial penalty. However, I'm not sure my doctor's office knows how to file one of those, and I'm fairly new to medical/insurance snags, and so don't know how to proceed.
(Based on a couple of other interactions I've had there around the same time, I have reason to believe that said doctor's office has no real admin staff at present. Scheduling appointments, etc. is done via an outsourced patient portal system. The person I've spoken to over the phone the past few times I've called there about it is the nurse I saw when I first visited.)
The first time I discovered that I would need this notification, I called the doctor's office and spoke to the nurse, and she said, "Oh," like she didn't know she needed to do that. I tried to do it myself with the insurance company, but they told me they needed to speak to an RN or someone who had access to the medical lingo.
A few days after that initial phone call, I called my insurance company and asked if it had been done. It hadn't, and I called the doctor's office again, and asked that they tell me when it has been done. Their response was, "Okay, I will let you know when it has been done." This was last Friday.
My MRI is next Thursday, and I'm starting to get a little worried, as the insurance penalty in this case is half the cost of the MRI. It's very frustrating and even stressful to think about.
I feel really stupid posting this, hence the anonymity. But it's my first time dealing with anything like this-- my only experience with tests, etc. has been with offices who have admin staff, and I wanted some insight as to how to proceed. This is in NY, if that helps.
(Based on a couple of other interactions I've had there around the same time, I have reason to believe that said doctor's office has no real admin staff at present. Scheduling appointments, etc. is done via an outsourced patient portal system. The person I've spoken to over the phone the past few times I've called there about it is the nurse I saw when I first visited.)
The first time I discovered that I would need this notification, I called the doctor's office and spoke to the nurse, and she said, "Oh," like she didn't know she needed to do that. I tried to do it myself with the insurance company, but they told me they needed to speak to an RN or someone who had access to the medical lingo.
A few days after that initial phone call, I called my insurance company and asked if it had been done. It hadn't, and I called the doctor's office again, and asked that they tell me when it has been done. Their response was, "Okay, I will let you know when it has been done." This was last Friday.
My MRI is next Thursday, and I'm starting to get a little worried, as the insurance penalty in this case is half the cost of the MRI. It's very frustrating and even stressful to think about.
I feel really stupid posting this, hence the anonymity. But it's my first time dealing with anything like this-- my only experience with tests, etc. has been with offices who have admin staff, and I wanted some insight as to how to proceed. This is in NY, if that helps.
I agree with treehorn. It sounds like you need to get prior authorization done. When I had my MRI done, the prior auth was done by the doctor office, but if you aren't getting any traction there, contact the place that is going to perform the MRI and see if they can't help, they need it for their files too.
(The prior authorization gives the insurance company a chance to review why the doctor is ordering the MRI and say, hey, do this instead because it's cheaper/that problem doesn't warrant an MRI. If you cannot get this done in advance of the MRI, I would personally seriously reconsider rescheduling until it gets worked out depending on the reason for the MRI.)
posted by Apoch at 12:42 AM on December 9, 2015 [2 favorites]
(The prior authorization gives the insurance company a chance to review why the doctor is ordering the MRI and say, hey, do this instead because it's cheaper/that problem doesn't warrant an MRI. If you cannot get this done in advance of the MRI, I would personally seriously reconsider rescheduling until it gets worked out depending on the reason for the MRI.)
posted by Apoch at 12:42 AM on December 9, 2015 [2 favorites]
Who handles your doctor's billing? They might be the ones to arrange this, which is why the nurse didn't seem to know what to do. I agree with checking with the place that's going to do the MRI, too.
posted by peanut_mcgillicuty at 4:26 AM on December 9, 2015
posted by peanut_mcgillicuty at 4:26 AM on December 9, 2015
I had to get pre-authorization to 1.) see a cardiologist and 2.) to get an MRI. Both were supplied by my doctor's office. It seemed super-routine for them.
A tip if you do everything right, but the insurance company says you didn't: if your health insurance is through your employer, and you have an HR department, chances are good that someone in HR liaises with the insurance company and can work wonders at cutting red tape. In my case, Aetna was claiming that my doctor had not provided one pre-authorization when I had it in writing that he had. When Aetna's response was that I needed to FAX my documentation (not email, not mail) for their review, I called bullshit and contacted HR. I had my "all taken care of" response three hours later. YMMV.
posted by Short Attention Sp at 5:21 AM on December 9, 2015
A tip if you do everything right, but the insurance company says you didn't: if your health insurance is through your employer, and you have an HR department, chances are good that someone in HR liaises with the insurance company and can work wonders at cutting red tape. In my case, Aetna was claiming that my doctor had not provided one pre-authorization when I had it in writing that he had. When Aetna's response was that I needed to FAX my documentation (not email, not mail) for their review, I called bullshit and contacted HR. I had my "all taken care of" response three hours later. YMMV.
posted by Short Attention Sp at 5:21 AM on December 9, 2015
I work doing this for a living, in a physicians office. What you need is an authorization. (sometimes called notification). Whoever the referral person is in your physicians office would be obtaining this FOR you. They have to submit your information and answer a few medical questions about your condition for the authorization to be approved. Sometimes this process, depending on your provider, can take anywhere from 5 minutes online to two weeks if they're being difficult.
I would call them the day before your exam is scheduled and make sure they have the authorization information approved before you head to your appointment the next day.
posted by Sara_NOT_Sarah at 7:18 AM on December 9, 2015
I would call them the day before your exam is scheduled and make sure they have the authorization information approved before you head to your appointment the next day.
posted by Sara_NOT_Sarah at 7:18 AM on December 9, 2015
This shouldn't be a thing. I had an MRI recently.
The doctor who recommended the MRI scribbled some things on a form. I brought it to the front desk when I was leaving. They scribbled on another form, gave it to me, sent me down to the MRI company (same building), where I made my appointment. MRI company called my insurance and then called me when the insurance approved the procedure. There was a 30 day window in which the procedure could be done if it was canceled/rescheduled.
Call whoever the office manager or referral coordinator is for your doctor. They're the ones who should be handling it as it's administrative paperwork. It should be a really easy process. A nurse is unlikely to be able to help you.
posted by zizzle at 8:29 AM on December 9, 2015
The doctor who recommended the MRI scribbled some things on a form. I brought it to the front desk when I was leaving. They scribbled on another form, gave it to me, sent me down to the MRI company (same building), where I made my appointment. MRI company called my insurance and then called me when the insurance approved the procedure. There was a 30 day window in which the procedure could be done if it was canceled/rescheduled.
Call whoever the office manager or referral coordinator is for your doctor. They're the ones who should be handling it as it's administrative paperwork. It should be a really easy process. A nurse is unlikely to be able to help you.
posted by zizzle at 8:29 AM on December 9, 2015
Given the lack of staff at your primary care provider's office, you might try talking the nurse through the requirements, like, "I need you to call phone number XXX-XXX-XXXX and tell them you are requesting a notification for MY NAME. They need to ask you a few questions about my medical history and symptoms." I would also call the MRI facility and explain what's going on -- they may be able to handle it from their end as well.
posted by jaguar at 8:47 AM on December 9, 2015
posted by jaguar at 8:47 AM on December 9, 2015
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posted by treehorn+bunny at 12:26 AM on December 9, 2015