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Smoke and Mirror Tactics

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gryndor

Member
What is the name of your state? California

I've been trying to get pre-authorized for surgery. I continually call the Insurance company to have them give me some consistant, concrete answers... but they apparently have no way to do either.

I called the other day and asked for a faxed copy of the requirements of this surgery and they said that that wasn't possible, but that they could tell me a few things verbally (over the phone). She continued to say, we need some information from your doctor in a letter. I asked what info, they said my doctor should know.

What's up with this? Is there some way I can pressure them into giving me their policies on certain procedures? When I get off the phone I am more confused than ever before.

Are there legal precedents in place to clarify insured-insurer communication? Are they allowed to use these smoke and mirror tactics to confirm or deny at their whim? They have given me nothing concrete and so there's nothing to hold them to!

Thanks for any help,
Gryn
 


Beth3

Senior Member
Slow down a moment. Apparently your doctor needs to write a letter to the insurance carrier substantiating the need for the surgical procedure. That is commonplace and your doctor should indeed know what information they require. He's probably had to do this hundreds of times.

I understand your frustration but no, you cannot force the insurance company to provide you with the medical guidelines they follow to verify whether surgery or a hospital stay is necessary. The insurance carrier has good reason to keep those confidential.

Is there a problem with your doctor sending this info to your carrier? If so, what's the problem?
 

gryndor

Member
I understand what you're saying, and there isn't a real problem with my doctor. I'm still unclear about who sends what when. I am mixed up between my surgeon and my PCP (primary care physician).

My surgeon didn't accept insurance, so the battle was mine to fight. I got fed up with the hassle and changed to a different surgeon.

I'm just frustrated that no one will give me a straight or consistent answer.
 

Beth3

Senior Member
I understand but what you know for sure is that the insurance company is requiring a statement from your surgeon stating your medical condition and expaining the need for surgery. This really is SOP and your doctor should know how to proceed. Call his/her office and tell them what you need the doctor to do. They should take it from there.
 

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