Why Is It Taking So Long to Get In for My Procedure?
Many patients voice frustration over the time it takes to get services approved. I wanted to take a minute to explain the process that occurs, just to ensure that proper payment of your claim takes place.
Specifically with HMO insurances it can be quite timely. Prior to initial visit, we often must request a referral from the Primary Care Physician. Although most are very efficient at getting right back to us, occasionally it can take a few days to get this referral. As you may understand, the PCP has hundreds of referrals to process and they must contact the insurance and give permission for the patient to be seen by us, “the Specialist”.
Once we receive the referral we are able to see the patient. The doctor evaluates the patient and decides the course of treatment and orders testing or procedures to be done. The staff will then have to check with the insurance company to verify what the benefits are on that procedure. There is no standard when it comes to benefits. Each insurance has several different plans and until we check directly with them, we will not know the benefits and cost to the patient, or whether it requires authorization. Once benefits are verified, we then must initiate an authorization with the authorization department of the insurance company. Occasionally this can be done on-line. Usually it requires filling out additional forms and sending medical records and imaging along with the forms in order for insurance to review the validity of the procedure. It is then time to wait again. It can take 7-14 days to hear back regarding an authorization. At Shim Spine, we are very diligent about following up on these authorization requests, checking on updates every couple of days. Once we hear back from the insurance company, we will call the patient to arrange a date for the procedure.
It can seem sometimes that patients sometimes wait an inordinate amount of time to get their procedures or tests scheduled. As you can see, it is often frustrating to staff as well, as we would like to get you in as soon as possible. If these steps are not followed and we were to schedule a procedure or test without the proper authorization, insurance will deny payment and financial responsibility will fall to the patient. This would not make patients very happy. The next time you have a test or procedure ordered and are wondering why is it taking so long, please know that it is our desire to process this paperwork and get the patients scheduled as soon as possible.
This blog is the opinion of Dr. J Shim based on over 20 years as an orthopaedic spine surgeon.