It may be no surprise to you that 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 pre-authorizations are, what they mean 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 either now or in the near future.  Moda and Blue Cross and Blue Shield also require pre-authorizations.

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 pre-authorization would be sent to your insurance prior to even your first appointment. This is the first step in an illogical flow. It is impossible at that time for us to know your diagnosis, what care will need to be rendered, or what services will be needed. As such, we generally have a window of several days after the first appointment to submit a summary of the treatment that is needed.

Often times we are asked to enter information manually on a website that limits our ability to store consistent information (like our clinic’s fax number) or to 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 the same data for you over and over again, despite the fact that this data is ALWAYS linked with your insurance policy. We are then asked questions about your clinical condition. This creates our first major work point.

Move Better Clinicians need to submit forms online.

Next, we need to 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. You must return these quickly, before the insurance-mandated window of submittal expires. This is our second major work point.

You need to fill out forms.

After we submit the required information, the insurance company then authorizes a certain number of visits and units (how much physical therapy and chiropractic care we can provide) 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 company is ENTIRELY controlling how much care you are permitted to receive. The additional burden here is that the insurance treatment plans do not reflect in any way what we think is clinically necessary for you to achieve the level of health you want. Often 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 forms again for the same condition.

Then you need to fill out another form.

At this point, your insurance company can completely deny continued care for your original condition, regardless of how you feel. So, even though you still have significant pain, your insurance company may decide that additional medical care is not necessary. Then the only option 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 sometimes goes to your left hip. We then would have to be very concise, submit for your low back only and focus all treatment under that. After that pre-authorization expires, or until we are no longer permitted to continue an appropriate level of care, we would submit claims for treating your left hip only. 

This process is an unnecessary waste of life for everyone involved. 

As a clinician, the pre-authorization requirement is extremely defeating and frustrating. It makes us feel like our exams mean nothing, our clinical opinion is useless, and we are somehow less-than doctors. We are essentially turned into employees of your insurance company, because they dictate what we can and cannot do if your insurance is to pay for your care. And you, the person who is supposed to be the one whose needs the insurance company serves, are left at the mercy of its money managers. You’re forced to continue making those big policy payments even though you may not receive the treatments that resolve your pain or other issues.

This is why so many clinicians turn away from insurance altogether and accept only direct payment from patients. However, we do not believe that is the way to change the system. Our services are needed, valuable, and effective, and should be covered by the health insurance for which you pay a significant amount of money.

Often insurance companies try to disguise pre-authorization as a way to control 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 profit

That is too many zeros of profit for an insurance company to justify controlling how a person chooses to use their health insurance. We are furious about this. You should be, too.

There are organizations that have been formed to address this problem.  Check out Patients Rising Now to find out more and fight back.