Question
Hi! My husband had a doctor-prescribed brain MRI a few months ago, and we didn't realize, nor did the doctor or facility tell us, that we needed pre-authorization from our insurance company, Horizon BCBS (it's a PPO). He had had several previous tests at the same imaging facility, such as an EKG, ultrasound, etc., and none of those needed pre-authorization, so it never occurred to us that the MRI might. Horizon refused to pay the charges (about $6,000!) based on the fact that we didn't get pre-authorization. I appealed the decision (I included a letter from our doctor stating why the MRI was medically necessary and a letter of my own explaining that we simply didn't know we needed pre-authorization), and my appeal was denied, again based simply on the fact that we needed pre-authorization. I am preparing a second-level appeal, and I'm not sure what more to tell them that they don't already know. It's very frustrating, because under our plan, this is a test that would definitely have been covered had we asked ahead of time, and it seems like they are trying to "weasel out of it" based on what essentially is a paperwork error. I'm scared because there's no way we can afford $6,000 in medical bills. What should I include in my second-level appeal, and do people with this type of problem ever prevail against insurance companies? Thanks.
Answer
Hi Amanda!
Yes it is a way an insurance company can save money.........what I would suggest is to get the Dr to give you a letter stating the reason they did not get a pre-auth.........they should have known to get one.........if they had called your insurance company to ensure you still had benefits then they would have been told that you needed a pre-auth.
Let the Dr take the blame and write a letter and perhaps you may have a better shot of them paying.
Good Luck!
Tricia
