I agree that patients should request these things ahead of time. But, there are situations when a sudden onset of illness or problem happens and it may be when a physicians office is closed. With some insurance companies you get a 3 or 7 day period of time to submit a referral (by backdate) if you were unable to obtain the referral by the date of the patient visit. Regarding pre-certifications, you do not get a backdate time to submit a request because the test has already been performed. A medical office becomes really busy and chaotic with the many doctors and that transition of care requests for medical records, referrals and or pre-certifications. As a result, there is always that referral or precertification that was not done due to the patient not knowing they needed a referral or the fact that they made an appointment and did not inform their primary physicians office and thus; the patient gets billed for the visit since the physician did not get paid from the health insurance company.
It is usually best to obtain a referral or pre-certification prior to the physician or facility visit so that it is approved and no one will have to pay extra because something is not approved. As a matter of fact yesterday, I paid less for a bus ride that went longer than my usual stop. The medical field is nothing like that. You go for one visit and then you have to complete your entire health care, sometimes somewhere else and it then gets complicated with referrals, authorizations ect., and of course the cost including time and aggravation. With western medicine you end up paying more. When you're going the longer distance it would pay to spend less. See, buses allow you to transfer to get to your destination with a one fare charge, cabs do not! Buses charge the same no matter how far you go, cabs don't! Besides I was never in an anniversary mood!
To alleviate the amount of denials and non payment issues as a result of referrals and authorizations not being approved by the time of service, insurance companies and other companies that perform precertifications and approvals on behalf of a health insurance company should allow more time to obtain precertifications and referrals. In the situation of a referral or precertification not being done by the day of service due to a physicians office being extremely busy or "Out of the Office"; the medical staff can obtain a referral or precertification with enough time allotted so that it can be approved, even if peer to peer is suggested. Peer to peer, is when a physician talks to another physician from either the insurance company or the company that does the pre-certifications on behalf of the insurance company to provide more information about the patient from physican to physican discussion, which is sometimes more effective; without having to go through an appeals process automatically since the visit or procedure as already been done. The appeals process takes more time and by then payment is rejected for the physician and that cost or a certain amount of it, is then the patients responsibility.
More time to issue a referral or precertification means fewer appeals. Payments and other issues will go a lot faster! What about medications? As long as patient's keep their appointments and notify the physicians office a week before their medications are finished, they will be refilled accordingly. If the patient begins to feel as though they are neglected, when they have called the office despite keeping all of their appointments and routine lab work; the pharmacy should issue a temporary supply of about a week's worth of medications and then send that emergency dispensed refill notification to the physicians office so that the physician knows they did not send in the refill request to the pharmacy. The physician's office will contact the patient and pharmacy regarding the medications when they arrive to the medical office.
Now, who get's paid to think and why? Is the job that I do a job that requires one to think? If so, then why is the minimum wage still less than $25 an hour? Remember- emergency situations should not require pre-certifications or referrals.