PPOs And Pre-Approvals

What is a health insurance 'pre-approval'?

Pre-approval in a health insurance context is this way that there's someone now interfering between the doctor and the patient to help reduce costs. And so you must not just ask your doctor, "Do I need this procedure?" but someone on behalf of the health insurance interferes with the doctor-patient relationship. Thus you must have your office call ahead of time to say, "Will you pay for this?" So in many circumstances, if you're going to have some form of a surgery, the doctor must call the health insurance company and get it pre-approved. In the old system, you would go have the surgery, the bill would be sent to the insurance company, you would get the care you need, and then later on, there would be some kind of negotiation between the insurance company and the doctor. In this system, most significant surgeries are going to require a pre-approval, a blessing by the health insurance company, to in turn, get you the surgery you need.

Should I get pre-approvals or treatments from my PPO provider?

It is very smart to seek out pre-approval because that eliminates the fight that you're going to have later to get it covered, with one exception. If it's an emergency need, if it's something that may make the difference of life and death, don't worry about pre-approval. Get the medical procedure you need, as long as you have someone to do it. Do not wait or delay treatment of a bad disease just for the pre-approval.

What are the pitfalls of seeking pre-approvals from my PPO provider?

Most insurance companies will require pre-approval of certain procedures. And yet they do use that as their red flag to say, "Oh, this person has become costly. This person may have a cancer diagnosis." And then they start looking back at your application: Did you write everything correctly on your applications? Sure, it's a red flag. But it's a means to get them to cover, and contractually to obligate them to paying for your procedure.

What documentation should I keep when dealing with my PPO provider?

When dealing with your PPO provider, it's important to keep a copy of your insurance receipts. You get these papers in the mail of "You pay this, we pay this much" and it's very confusing. But it's important to, whether you can read those or not or even interpret them, to just save them in a file because it helps document what they agreed to pay for. Also, each of your doctors' offices will have what's called a pre-approval form. You want to get a copy of that pre-approval form to show that a person sitting behind some desk in New York City approved this. And there's usually a number on it. Because later on if it's denied, you have that as an ability to fight, to say "No, you agreed to it contractually, and got the treatment in reliance on that. And now, contractually, you're obligated to pay."

What if my PPO provider rejects my pre-approval request?

If your PPO provider rejects your pre-approval request, you ask again. You have your doctor first and his staff ask for it, and then you argue. Your first line of argument is always medical necessity. We advise people as a self help measure to write to the CEO of the company. Now make sure that it's not a serious, immediate or urgently needed surgery, but you write the CEO of the companies name on the envelope. You put it in a FedEx letter. It costs $17 but those things get read. You tell him what you need, and that its medically necessary and that its been denied. That kind of heightens the processing, and gets people at significant levels of the company to look at your specific needs. Tip: Keep date copies of all correspondence with your health insurance company. The squeaky wheel with insurance gets the grease, and it's labor intensive. Usually when you are sick, you are at your most frail state, you have the least ability to fight, but that is when you need to seek out a family member, a friend, or someone to write on your behalf and write ceaselessly. Contacting them, faxing them, and doing anything you can because the squeaky wheel will get the grease.

What if my PPO denies me recommended treatment?

If your PPO denies you a medically necessary treatment, get your doctor involved, get the broker who sold you the insurance policy involved, and write to the CEO of the company detailing what happened. If it is a very urgent thing, find any means to get the treatment and then worry about paying for it later.

What if my PPO refuses to cover a treatment because it is 'experimental'?

Insurance industry companies which have denied things based upon the case being experimental have gone away in many ways, because they cannot define experimental. What is experimental to one person is not experimental to another, so usually they are denying it under a concept called investigatory. What you need to do is talk to your doctor about that term. Look at the definition in the book and then discuss how medically necessary the treatment is, because you always argument that the procedure is medically necessary regardless of what the insurance company wants to cover. You're also looking to the exclusionary causes. Are they specifically denying a bone marrow transplant for a stage three breast cancer patient? Or are they just denying things generally. The law usually requires a denial to specificity act with a specific procedure. The insurance company wants to stay as vague as possible. So, you can attack the exclusion of your treatment based upon how general their exclusion is. In general, you cannot define experimental or investigative and the tide should go to the insured needing the care.

What should I watch out for if I can't get pre-approval from my PPO provider?

When you write a letter about your procedure, be real careful not to adopt or accept the language that the health insurance company is calling your procedure. There are people that will write and say "My procedure," "the insurance company is calling my procedure experimental," and "my experimental procedure." Don't ever adopt their language because that's almost looked at as an admission that you understood what they meant and that you accepted their language, when their language and definition is written in their contract and what a doctor calls experimental may not be the same as what an insurance company calls experimental and nobody can define it. Remember, the insurance company is obliged to honor the definitions of the words they write, so it doesn't matter what a doctor thinks. It's, does the definition fit the procedure that's in their insurance contract?