We've all been frustrated when referrals or authorizations don't happen as promised. There are fairly simple and straightforward steps you can take to facilitate this process to ensure you get the care you need in the time frame you need it.
Referrals and Prior Authorizations
Your insurance company may require a referral to see a specialist or obtain a second opinion. Similarly, you may need prior authorization for a specific procedure, lab test, or medical equipment. Since the processes are generally the same for determining if a referral or prior authorization are required, I’ll cover them together. Then we’ll look at the follow-up processes separately.
Do You Need a Referral or Prior Authorization?
It’s important to find out if you need a referral or prior authorization (also called a pre-authorization) because if you obtain services without the insurance company’s required approval, you’ll have to pay the entire bill.
Your doctor or someone on their staff may know if the pre-authorization or referral is required. You may want to verify their answer by calling your insurance company. If the doctor’s office is wrong, and you didn’t get required pre-authorization, you are responsible for the entire bill.
You can get the Summary Plan Description from your insurance provider or from your employer if you get your insurance through them. This information will be in the section on Pre-Authorization.
If you call your insurance company for a pre-authorization, have your diagnosis code (also called an International Classification of Diseases, or ICD code) handy. Your doctor or their office can give this to you. Since there are over 70,000 ICD codes, having your specific code will help make sure you get the correct answer for your situation.
Whenever you speak with your insurance company representative or your doctor’s staff member, get the person’s name, and time you called. Write this information down along with whatever you're told. Repeat back to the person your understanding of what was said. Note that they confirmed the accuracy or modify your notes to match what they have told you. Don’t hang up until you have all of this information accurately recorded. Keep those notes in case you get a different answer or surprise bill later on.
Let’s say you need a referral to a specialist. Your doctor places the referral. Ideally, this process should all be seamless and require no effort from you. In an ideal world, the doctor places a referral, the office processes it within a week, sends it to the specialist and the specialist's office calls you to schedule it. However, I have experience too many times where this process doesn't happen in an ideal fashion and it's helpful to know what steps you can take to advocate for yourself to ensure you get the referral you need.
Here are the things you need to do in order to follow up the request:
- Know how long the request should take to result in an appointment
- Call the office back if you haven’t heard back in a week or by the date they gave you. Ask to speak to the person responsible for handling referrals.
- Get the name and number of the person with whom you speak. Before hanging up, ask them when and how you will hear back. Make a reminder to yourself to follow up at that time if you haven't heard.
- If you haven't heard back by the promised date, call that person back. Remind them that you spoke on x date and that you were to hear by now. Ask the status of the referral. Again confirm when and how you will hear subsequent status and make a reminder to yourself to follow up again at the promised time.
- Elevate your issue to their supervisor if you’re not making headway.
- Once the referral has been made, call your insurance company to verify they have approved the referral.
- Get the name of the person you called and confirmation number of the approval if they have one.
- Usually the specialist's office to whom you've been referred will reach out within a few days after they receive the referral to schedule your appointment. If they haven't, call them to schedule. If they still need to review the referral, again ask by what date you should hear and set another reminder for yourself.
Now let’s say you need a pre-authorization for lab work. You generally follow the same process you used for referrals.
- Know how long the request should take
- Call the office back if you haven’t heard back in a week or by the date they gave you
- Speak to the person who was supposed to make the request
- Get the name and number of the person you call
- If they say they’ll get back to you, make a note of it
- Call that person back if they say they will get back to you
- Elevate your issue to their supervisor if you’re not making headway
- Once the referral has been made, call your insurance company to verify they have approved the pre-authorization.
- Get the name of the person you called and confirmation number of the approval if they have one
Unlike referrals, most insurance plans have deadlines for the insurance company to approve or deny your request. There are shorter deadlines for urgent situations. This information is in your Summary Plan Description under Pre-Authorizations. Make sure the insurance company responds by the deadline.
If the request is denied, ask your doctor if she will file an appeal or re-file the request with additional information. Then follow steps 1 – 6 above to track that submission.
As frustrating as the follow-up process can be, remember this: Most people at the doctors’ office and insurance company are doing the best they can. Maintain a professional, calm tone as much as possible when speaking with staff and representatives. If you’re getting nowhere, you can always ask to speak with a supervisor.