Pre-certification

The word Pre-Certification or Pre-Authorization is one that can stop my heart for a beat. We do it daily, even hourly in our radiology department. It seems rather strange that if a doctor says that Joe Blow needs a CT Scan for a collapsed lung here in Iowa that there is some "nurse manager" in some other state, lets say Connecticut that says "no, sorry, this rationale does not fit an 'appropriate 'standard of care" for this patient. "What other imaging has he had?" "did the doctor try medication?"

I wanna say "um, this guy is looking like a fish outta water, I don't think he can breath is that good enough? I mean we need to find out why this guys lung collapsed". Silence on the other side of the line. Then "have the doctor call me" she says.

So I sit and watch the man in the waiting room. Wondering.."how long will it take me to get him to the emergency room when he passes out"? "should I take him to the emergency room?" "Now that his insurance knows that he is here, would they pay for an emergency room visit?"
The patient is looking at me.

It is getting better. It seemed not to many years ago people thought we called the insurance companies just so WE could get paid. But now most people realize that THEY WILL HAVE TO PAY if we do not do this pre-authorization.

Some insurance companies do not require it, some have 2nd and 3rd party payers that handle it and we have to call both. There are a few companies that strike terror in our hearts. United Health Care and Heins and Associates are two. Not that most of the people on the other end are not nice. That is not the problem. It is that they have their marching orders and they stick to them. They do want to keep their jobs and keep their insurance.

I am just getting older and when I hear the stories from families that are farming and or own their own business and are paying out of pocket anywhere from 500-2000 dollars a month for health care and they still have to meet individual and family deductibles of over 2500 dollars or more before one outpatient procedure is covered at even 80 percent..well it makes me so upset.

There are people like my sister that thought that McCains plan of giving everyone a 5000 dollar credit for health care was such a great idea. Yeah, well she and her husband have a pretty good plan. It costs them about that much a year. They are healthy, middle aged and make well over 250,000 a year. So 5000 dollars just doesn't seem like a lot of money. I don't think she has had a major medical expense ever. So she would not know how much it would really cost her if she did have say...open heart surgery...or have to wait to get a CT when she can not breath. AND if she did have to pay a 2500 deductible for some thing, she would write a check. Don't get me wrong. I love my sister to death and I understand her point of view. But the point is that there are a lot more people that make a whole lot less than that in this country. And while 5000 dollars toward a credit would help. Most people could not afford to get insurance to start off with. That 5000 dollars is just a credit at the end of the year. It does nothing to pay the monthly installments to keep the insurance current, or pay the deductible so Joe can have his CT.

I have a good job and have great insurance. But I pay 350 dollars a month for family and have a 1000 deductible to pay out. They do cover preventive medicine, like physicals and mammograms and such. So yeah it is good. But it costs me well over 5000 dollars a year. So that would not have helped me a whole lot.

I am ready for the fight on health care. I am ready to hear the words "we are going to have to cut pay". If it means that everyone can have health care, no one is turned away. I am ready. In the long run, it will cost me less than the 350 dollars a month and 1000 dollar deductible I am paying now.