The issue of pre-certification and authorization for studies has always been an issue for me when dealing with medical insurance companies. Beyond lab work and x-rays, all other studies require pre-approval.

I have asked on many occasions the purpose of these data, and the response is always that it is standard operating procedure. There are cases both for and against insurance company precertification and authorization, but ultimately, we as healthcare providers are seeking to identify the cause of a patient’s specific complaints.

These complaints — noted in the patient’s initial history and physical — are the guidelines I follow for determining how and why a certain study should be ordered. But many times I have to talk with a nonmedical person to argue my case.

Despite my education, an insurance technician that’s been trained to read a manual makes the decision about which studies can or cannot be done. Even if I explain in great detail the medical need for a specific study, in my experience, the insurance tech will still tell me there is no indication.


Continue Reading

Typically these interactions take three days from the initial call to the time the insurance company calls back. When they do call back, they usually want more information.

Realize the healthcare provider has already provided much of the information during the first request, and now has to come up with excuses to get data needed to make a diagnosis. Arguing with nonmedically trained insurance representatives is both time-consuming and frustrating for my staff and myself.

With all of our training, healthcare providers should call the shots to decide whether a study is needed to assist in a patient’s care and treatment, but instead this responsibility falls to an uneducated tech. How in the world did we allow this to happen?

In addition to these hassles, there are many other problems with insurance companies today, including low reimbursement for healthcare providers and high costs for patients.

Copayment costs are increasingly becoming a deterrent to patient care. I have many patients with HIV and/or hepatitis C who do not come in for their maintenance visits because they cannot afford insurance. As a caring physician, I have waived copayments for patients who need care and cannot afford it.

This leads to even an even lower reimbursement from insurance, since a $50 copay is usually the bulk of the payment for a visit. If an insurance company reimburses $16 to $30 of the cost of care, I have no recourse but to accept this. At that pay rate, not even a plumber or electrician would come out to service my home or business.

Is healthcare the only profession where fair trade does not apply? Providers are increasingly forced to see more and more patients in order to maintain our income and to afford the rising costs associated with carrying malpractice insurance and hiring support staff to haggle with insurance companies over reimbursement rates.

As the cost of healthcare increases, it seems the medical insurance industry is doing it’s best to pass costs onto healthcare providers and patients. Is this in the best interest of patient or the insurance company’s bottom line?

Patients have lost access to affordable healthcare, freedom to choose their physician and the right to medical care and medications unless deemed necessary by their insurance carrier. Somehow the medical field and the general public must find a way of gaining back some control.

If conditions do not improve, there will be a shortage of doctors. Healthcare providers cannot continue to pay increasing expenses and give quality patient care with the restrictions we have upon us at this time. I want to be a doctor, not a paper pusher or salesman. I believe this is what my patients want also.

Patrick Aufiero, MD, specializes in internal medicine and infectious diseases in Hamilton, N.J.