A well established ENT surgeon called MHM recently most upset her fees had not been paid in full and an excess deduction made even though pre-authorisation had been obtained.
The patient had contacted their insurance provider, cited the correct treatment codes and having confirmed everything is in order they were given a pre-authorisation number to cover costs of the treatment. This code was passed on to the consultant’s secretary prior to treatment. Not a problem.
Except the pre-authorisation number did NOT confirm all costs will be covered.
Pre-authorisation only confirms there is a policy in place and the consultant may submit her charges to the insurance company concerned. The consultant may even have an agreed fee structure with the insurance company or may be charging precisely in line with the fees set out by the insurance company. That has nothing to do with the excess on the policy.
This is not to say the patient is unaware. For sure when they contact their health insurance provider they hear clearly what is or is not covered. And further still if YOU call an insurance company are on hold to an insurance company some even play the message when on hold “pre-authorisation does not guarantee payment; it only confirms there is a policy in place subject to the terms and conditions of that policy” In other words, subject to the excess level you have agreed to.
Come excess time (see previous MHM article) the patient more often than not tries to fall back on “pre-authorisation” as a reason why they should not have to pay the consultant. It gets even more complicated when the policy is held by the patient’s employer and not by the patient themselves. Although in fairness in such cases most employer’s do reimburse the employee.
Explain it to the patients this way. If you take out car insurance whether you are fully comp or third party the chances are you will agree an excess of £100, £200 etc In other words, you are liable for the first £100 or £200 of the repair costs.
Its precisely the same with private medical insurance.
The bottom line though is whether your patient has pre-authorisation or not you may, as exampled by this particular ENT surgeon, still find yourself out of pocket IF there is an excess. Pre-authorisation will NOT stop such incidents.
It’s not designed to for pre-authorisation does not authorise anything; it only confirms there is a policy in place.