Has your doctor ever told you that your care, or your test has to be pre-certified?
Pre-certification is required for common tests such as an MRI and other advanced diagnostic test. Pre-certification has effectively been used to decrease the amount of tests ordered simply because doctors for years have ordered too many tests. It is not common for Magellan or for other companies who are hired by large insurance companies to be the gatekeepers for tests that may cost $800 dollars or more.
It is also common for your chiropractor or therapist to have to certify care under an automobile carrier simply because the law requires it in NJ. The procedure involves filling out a state of NJ form and then sending in the amount of visits and procedures required for the month of care that is needed for the patient. As long as the care paths are followed, and the doctors submits good notes, most care is approved.
The most recent precertification plan by Aetna who is using NIA/Magellan requires each services to be certified through their web site by your healthcare provider. Rather than just certifying the amount of visits required, NIA has devised an algorithm that actually pre-denies care. The initial rollout has frustrated doctors and patients alike. Imagine that your chiropractor has performed an examination on you and determined that you will require a reasonable trial of care for acute back pain of 8 visits. Magellan will often deny most of the procedures, exercises and manipulations that your doctor needs to get the job done right even when highly detailed electronic notes are submitted with the request.
Your doctor may not tell you this initially, but it is likely that they needed to go back on the web site, and request additional units and resubmit their notes. They do not get paid for this additional work. Magellan/NIA’s current scheme also is near impossible to track by computer, forcing doctors to worry for you about appropriate care that is often denied. As a provider who advocates for their patients, this should be illegal. The doctors who work for Magellan on secondary appeal are often confused by the complexity of their current methodology as are the treating providers.
Our patients have been notified that they are responsible for any care not approved however, so far, very few patients have required appeals. Many are scared to use their insurance which is ridiculous. While patients are at risk, the truth is, this is hurting their doctors as well with wasted time spent to authorize care for an insurer who often is paying less than the patient does after their high copayment. It is unethical but is it illegal? Does this serve any purpose at all?
Considering the current problems with pain care, opioids, and how chiropractic and physical therapy offer solutions to an expensive and dangerous trend, insurers just do not get it other than Optum healthcare who has admitted that they have saved so much by using chiropractors and therapists that they are rolling out a program to make these providers costs less. They recently introduced a new program to incentivize patients to avoid drugs, medical procedures and surgeries that may leave them worse off and use chiropractors and therapists first. While on the surface, this sounds great, the problem is that they stopped paying chiropractors for their initial evaluations over the last couple of years and relied on a global fee scheme, forcing many doctors to drop the plan due to the economic unfeasibility of working with them. We dropped Oxford, one of their plans for that same reason. Considering the rising costs of rent, supplies, employee salaries and the general cost of living, many practices may not want to see this new influx of United Healthcare patients.
Their newest scheme seemed to coincide with the latest Aetna/CVS merger which may be just a coincidence, or maybe it is a corporate scheme to help CVS save money on the backs of the patients they now insure under Aetna and the doctors who serve them.
Aetna does have a history of some misdeeds such as blackballing insured patients who work for self insured companies or denying care outright as recently was discovered in a California trial without ever looking at the notes on the case.
Patients must fight back to win; here’s proof that it works.
Patients are fighting back. They are contacting the HR departments in their places of employment and letting them know that this is unacceptable. Some have already won the battle by making their problems known.
The good news is that employers are listening and switching to insurers who actually insure their patients. Examples of this recently include the townships of Edison who recently switch to Horizon Blue Cross Blue shield from Cigna who often uses third party companies to under-pay doctors and deny needed services using ASHN to do their dirty work.
Elizabeth board of education also recently switched back from Aetna, after there have been numerous complaints about care being denied.
There are likely to be other employers who will also consider switching as well, however, they will not do so unless they know what you are experiencing. It is up to you.