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Ok so prior to switching to the agent side I actually worked in hospital billing.
Certain carrier are notorious for giving providers a hard time without saying names it starts with a W. I have had scans to check cancer progression denied, forced discharges on psych patients 3 days after a suicide attempt, delayed cancer treatments, etc.
I most of these cases it took multiple peer to peer reviews. The hospital is on top of this but as you can imagine having a doctor or social worker on the phone for hours per denial is extremely time consuming.
As for the theoretical aspect if something is deemed life threatening or an emergency they do not have to wait. If it is not and the provider does the procedure, test etc they eat the costs because 9 times out of 10 the insurance companies will not give a retro-prior auth. This leads to hundreds of thousands of dollars in lost revenue.
Now I know hospitals inflate prices and some may order unnecessary testing (hence the need for a prior auth) but this is a real issue.
I tell my clients with significant health issues that Original Medicare is usually the best way to go, should they be able to afford a supp or get Medicaid.
It is unfortunate but here in Maine and across the country many hospitals are on the verge of closure or are closing whole floors/departments because they are struggling financially. Spending resources on prior auths definetly can have a big impact.
Are you by chance enrolled in a WellCare product?
