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Is this a new "con game" by Insurance Companies?

Posted by sean on March 11, 2001 at 09:51:27:

My doctor's office sent a 'letter of medical necessity' couple of weeks ago to my insurance provider (BC) in order to obtain pre-authorization for a genioglossus advancement/hyoid suspension surgery. My doc just received a letter of response from BC last Friday. I'm reading a copy (sent from my doc) and had to shake my head. Here's BC's response to my doc:

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"BC of California is making some changes that will make things easier for you. You will no longer need to obtain pre-certification from us prior to most outpatient procedures. Although your Explanation of Coverage may continue to state that we do required pre-certification, Blue cross does not require you authorization of the procedures. We will, however, review for medical necessity when a claim is submitted.

Please note that this letter does not guarantee payment. Benefits determination cannot be made until we receive and review your claims for those procedures. These claims will be subject to all policy exclusions, limitations and conditions, including any applicable per-existing conditions, and the exclusion from coverage of services that are not medically necessary. And ofcourse, no benefits will be payable if your coverage is not in force when the service is rendered.

If you have any questions about this good news, please call your BC of california Customer Care Associates."

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Just wonderful...I really love it when they call it "good news".... ;->

Why wait AFTER surgery to approve or deny the claim? Why this sudden change in policy about pre-authorization? Sounds to me like a quick and convenient "backdoor getaway" for BC. Is this another step in the direction for insurance companies to make decisions based more on financial considerations and not on medical considerations? I mean, from a purely medical point of view, BC already has the necessary medical data to make a determine as to whether I should or should not have this surgery: My medical history, the letter of medical necessity, etc. Nothing really can be added to this info after the surgical procedure, medically speaking. BC will still have to make a determination based on the current medical data they already have. (Or gee, is BC going to cover the surgery if it was successful in curing my apnea, but won't cover it if it failed?...I mean, really ;->)

Needless to say, I'm contacting BC this week. Can't go into surgery not knowing whether I'm going to end up holding the bag or not...Any comments and insight on this is much appreciated.

thanks,

sean

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