Numerous times when I’ve sent an invoice for an excess or a shortfall, the patient telephones and quotes the pre-authorisation to me claiming their insurance company will settle the account.
In other words, the patient claims the pre-authorisation number is a guarantee of payment. In reality it absolutely is not. Consider what really happens when the patient has contacted his/her insurance company and been issued with a pre-authorisation number.This does not mean the insurance company will accept your charge.
A pre-authorisation number merely confirms the patient has a policy in place and charges will be excepted subject to the terms and conditions under that particular policy
This happened to an MHM client – a gynaecologist – recently. We spoke to the insurance company concerned who advised whilst they did indeed issue a pre-auth, this did not mean they would accept the charge.
Yet in this actual example, pre-authorisation had been refused.
Again the message came through loud and clear: Pre-authorisation is not a guarantee of payment.
No argument from me. It has always been so. My issue though is why did the insurance company issue a “DECLINED” pre-authorisation? If they were not prepared to issue a pre-authorisation then they should not have issued one at all. There is NO WAY I’d be able to tell if the pre-authorisation was acceptable or not.
It transpired the patient’s policy specifically excluded an initial consultation. There is no problem with that for it is up to the patient to understand what is or is not covered on their policy. Indeed policies with such restrictions are becoming more and more common. Why? Because policies with such exclusions tend to have a lower monthly premium.
Therefore in my view, no pre-authorisation should have been issued at all.
This point was duly made to the insurance company who were not able to consider the comment. They had always done it that way. I have the utmost respect for private medical insurance companies most of whom are extremely efficient and willing to help. Whilst I’ve had numerous disagreements with all of them regarding fees or associated issues, never have they implied or stood behind the “we’ve always done it that way” position.
But on this occasion, it feels very much like a case of stop wasting your breath! Yet this particular insurance company has many times expressed the view private medical professions and insurance companies must work together to both stimulate and provide the best private medical offering.
Does not feel like that from my chair!