Understanding the Role of a Health Insurance Authorization

Whether you have an HMO or a PPO most tests and procedures and even equipment will require an authorization from your health insurance.  Generally people think this is just some paperwork that needs to be done, however there is significantly more to this procedure than meets the eye. 

The insurance company will ask for the doctor’s notes about why you need the procedure, your medical history and any supporting documents.  If there is not a certain diagnosis or a specific medical history than the order will be reviewed by a medical review board, a group of people made up by nurses who have been trained by the insurance company.  If certain criteria are not met the order will be denied and a different procedure may be ordered. 

If the doctor does not agree with the insurance they can ask for a peer to peer review where your doctor can talk to an insurance company physician.  Your doctor must make the case of why you need this procedure and another one cannot be done.  The insurance company can still deny the procedure. 

When you come to the sleep lab and we are telling you that you have to have a home sleep test it is usually after we have gone through every avenue available.  We want to follow your doctor’s order but we understand that there is a balance. 

Sleep labs now employee one or more people to handle the need of getting authorizations.  They also make sure that paperwork that is necessary for the study and the possible therapy are obtained. 

Now think about the effort needed to get a PAP device.  You go to the doctor and get an order.  Someone must work with the insurance company to get the order for the initial sleep study or Home Test.  We must explain the decision and why the doctor’s order was changed.  We do the study then send the results to the doctor.  We go through the same thing for the follow up study or the therapy. 

Insurance companies have a lot of power on the care of a person.  Most people are unaware of this change in the decision making process. The bottom line is your health care is decided based on cost; not based on the best outcome.