Blindsided With Pre Pay Review

The end of insurance pre authorization as we know seems like a good thing but is actually a not so good thing for healthcare providers and probably patients too. It’s like lowering your kids allowance without telling them, because they took out the trash, but let’s face it, it was a small bag and an easy chore. Insurers continue to let more doctors, diagnosers, nurses, pharmacists, therapists and providers up and down the care continuum do the work, bill for it, only to find the payment downcoded, sometimes denied. It affects behavioral health and mental healthcare as much as any service. Cigna reviews all level 4 and 5 evaluation and management automatically, potentially downcoding before payment. United – which is somewhat going against tide adding pre authorization – has this year added more referral rules for specialists for Medicare Advantage beneficiaries, while Aetna is approving inpatient visits but then adjusting for severity, paying shorter stays sometimes at outpatient rates. The net effect of these policies can be more cost and uncertainty for patients, and those professionals treating them.  I can’t blame them. These moves are intended to try to contain the cost of care, particularly inpatient care, and pay fairly for the right level – which makes sense.  It is likely, one source told me, that the policies will extend into private practices and home services eventually, some already have.  I could argue the approach but I suppose I’m not much different – I automatically let our youngest enroll for another semester of university but later reduced the amount we were willing to pay for his 15 credits after that chem grade. “But my teacher said he didn’t care if we passed or failed,” Tommy said. Almost sounds like my doctor who’s paid to diagnose and treat, not micromanage my choice to have a glazed donut at 9pm on a Tuesday – which is delicious by the way. It’s parental pre-pay review, and while it can feel harsh and maybe a bit blindsiding, it is inevitable as we come of age – in healthcare and in life.