“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”
That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed. She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).
But her insurance company refused to authorize this critical test.
Why? Was there anything we could do to help?
We went right to work and here’s what we discovered:
- The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
- We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
- We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
- We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.
Lessons learned…
- Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
- Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
- Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
- If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
- Realize that by enlisting a private advocate, you save time and money and get results.