As the director of AdvoConnection and its associated websites, I hear about so many patient and caregiver complaints, problems, hurdles and – dare I say it – atrocities.
Among the most frustrating and egregious I hear way too often; that is, with advance permission from their insurer, someone underwent a test, a procedure, or surgery, or saw a specialist, only to be told later that the insurer wouldn’t pay for it after all.
If this has happened to you, you are probably vigorously nodding your head. It happens all the time!
If you have not yet had the experience, then your eyes may be wide open in horror! And I’m here to tell you the same thing could happen to you.
So let’s see how we can prevent that!
It’s actually not too difficult, but might be more or less so depending on what the permission needs to be, and how soon you need to get it.
The first thing to know is that there is very little black or white with insurance companies. Sometimes getting permission is just a matter of the day of the week, the time of day, or even the customer service rep you talk to. (BTW – as an aside – insurance customer service reps sometimes call themselves “patient advocates” Really? Who are they advocating for? Themselves, of course! Not you! So don’t be fooled.)
Not that your insurance plan doesn’t have parameters – it absolutely does. But there are so many gray areas, that one person might interpret coverage one way, and someone else might interpret it another.
So the key here is that you are seeking a promise of coverage ahead of time, before you undergo, or purchase, or visit something related to care. To do that, you call your insurer to get that promise.
Ideally all this will take place weeks before your medical care takes place. You may need that much time. Even if you don’t have that much time, take care of this as early as possible, because this work on the front end will possibly save you a great deal of grief – and money – afterwards.
Begin by asking your provider what the “CPT” and “DRG” Codes are for whatever you are seeking coverage for. A DRG (Diagnostic Related Group) is a code for your diagnosis. A CPT (Current Procedural Terminology) is the code that describes exactly what service or product you’ll be receiving (and eventually, what price is being charged for it.) There may actually be several codes involved. You need the most important ones. You might also ask what other information they can share with you, knowing you are calling to get your insurer to confirm coverage.
Now it’s time to contact your insurer. Be confident! Instead of asking about coverage, state it as a matter-of-fact: “Hello Mr. Insurance Customer Service person. I’m calling to confirm coverage for an upcoming procedure.”
They will look up your account to see which insurance plan you have. They will ask you what doctor has ordered your procedure to be sure you are in-network. Then you can give them whatever codes and descriptions were given to you by your provider to further that permission.
An aside: sometimes the doctor’s office has already supplied this information to the insurer because they are making some of the arrangements on your behalf. Remember – as much as you want them to be paid, they want to be paid, too! However, that does not change your need for that permission/ confirmation because – as stated above – insurers may change their minds.
You may have to reiterate that the purpose of your call is to get a “confirmation” (NOT a permission!) Then – VERY VERY IMPORTANT! – get it in writing. “Mr. Insurance Customer Service person, thanks so much. Now, I need a copy of that confirmation in writing. Email is OK, but I’d prefer postal mail. How soon can I expect to receive that?”
Finally, double check that they have your email address and postal address correctly listed on your account.
A few additional notes:
- Always ALWAYS ask for the name and extension number of the person who has confirmed your coverage and hang on to that until you get your written confirmation.
- If possible, don’t undergo the test or procedure, or fill your prescription – whatever you’re waiting on permission for – until you have that written coverage commitment.
- If the insurer says they won’t send you something in writing, then you’ll need to ask for a supervisor. Keep going up the ranks until you get a yes, then ask for it in writing and ask when you can expect to receive it. (Don’t forget to ask for the name and extension of the supervisor.)
- Finally – if you don’t receive your confirmation by the date you were promised, follow up with the person whose information you’ve recorded. (#1 above)
- If they say no, you are not covered… then it’s time to call in the professionals to get your claim approved ahead of time. Short term payment for long term savings. Call a professional advocate to help. Money very well spent! Possibly lots of money saved afterwards.
Lather, rinse, and repeat as necessary.
Don’t be one of those people I hear about who didn’t get confirmation in writing, and must now spend much more money to get a professional to figure it out afterwards!