Insurance is becoming more complicated. As of June 2019, Providence began requiring pre-authorizations, adding to a long list of insurance companies that have already required this. The purpose of this post is to explain what they are, what that means for you, and the general trend we are seeing in healthcare. Even if you do not have Providence insurance, this message will likely apply to you now or in the near future.  Moda and Blue Cross and Blue Shield also require preauthorizations.

A pre-authorization is a requirement for an insurance company to pay for services rendered at a variety of locations. These can be hospitals or small clinics alike. In its truest form, a preauthorization would be sent into your insurance prior to even your first appointment. This is the first step in an illogical flow. It is impossible for us to know your diagnosis, what care needs to be rendered, or what services will be needed. As such, we generally have a window of several days from the first appointment to submit what is needed.

Often times we are asked to enter information manually on a website with little ability to store consistent information (like our clinic’s fax number) or pull known information about you as a patient (such as your date of birth, which is always linked to your insurance number). This means we have to manually enter in the same data for you over and over again despite that data ALWAYS being linked within your insurance company. We are then asked questions about your clinical condition. This creates our first major work point.

Move Better Clinicians need to submit forms online.

We need to then collect data from you in even more forms. These forms are an attempt to quantify your current condition’s severity. As such, we will be sending you forms through your Jane account to complete and these must be returned quickly before our window of submittal expires. This is our second major work point.

You need to fill out forms.

After we submit the required information, we are then given a certain number of visits and units (how much physical therapy and chiropractic care we can do) as well as a treatment time frame (how long we can treat you for). This means that someone who has never seen you, talked to you, or worked with you is dictating your treatment. Your insurance is ENTIRELY controlling how much care you can get. The additional burden here is that the treatment plans are nowhere near what we think is clinically necessary for you to achieve the level of health you want. Often times they do not authorize enough visits or units which narrows our timeline of treatment.

Once your initial authorization has expired or run out, we need to submit the same information again. This is our second work point.

Move Better Clinicians need to submit again for the same condition.

You need to fill out another form.

At this point, your insurance can completely deny continued care for your original condition, regardless of how you feel. So, you can still have significant pain and your insurance company will not deem medical care necessary. The only out that we have as clinicians is to essentially rebrand your pain. Let’s say you came in for low back pain that starts in your low back and goes to your left hip sometimes. We now have to be very concise and submit for your low back only and focus treatment under that. After that preauthorization expires or we are unable to continue an appropriate level of care, we would submit for your left hip only. It is an unnecessary waste of life for everyone involved.

As a clinician, this is extremely defeating and frustrating. It makes us feel like our exams mean nothing, our clinical opinion is useless, and that we are somehow less-than doctors. We are essentially turned into employees of your insurance company as they dictate what we can and cannot do in order to use your insurance. This is why so many clinicians turn away from insurance all together and accept only direct payment from patients. We do not believe this is the way to change the system. Our services are needed, valuable, and effective and should be covered by the health insurance that you pay a significant amount of money for.

Insurance company can disguise this as a way for controlling excess costs and services. That is simply not true. United Healthcare made a $14 BILLION profit in 2019. That looks like this:

$14,000,000,000

That is too many zeros of profit to even think about controlling how a person chooses to use their health insurance. We are furious about this and you should be to.