I’ve come to the conclusion that for-profit health insurance companies are morally evil and should not exist. Sadly for us normies, they do, mostly because they’ve grown up over time in our society and are so ingrained it’s difficult for us to imagine a different way of paying for health care. But when you think about it, it’s absurd. Insurance companies make more money when they refuse to pay for patients’ health care. Therefore, they will refuse to pay for as much health care as they possibly can. Anyone who thinks otherwise is, unfortunately, kidding themselves. In our capitalist economic system, businesses will take whatever course of action maximizes their profits. Remember when chemical companies dumped their waste into all sorts of waterways because it was cheap and easy, until government regulations – including significant fines – made it unprofitable to do so?

Getting prior authorizations from insurance companies is, without a doubt, the worst part of my job. On the surface, prior authorizations sound perfectly reasonable – you have to get approval from the insurance company before they will pay for a test or procedure that the doctor has ordered. They say it’s to prevent waste and fraud. Untrue. The purpose of obtaining a prior authorization is to break the spirit and willpower of whatever unlucky soul is trying to get the insurance company to pay for something.

To obtain a prior authorization, the first step is usually to call the number on the back of an insurance card. Some insurance companies outsource their prior authorization departments to a third company. Some do it in house. Either way, the experience on my end is equally terrible. You begin with an interminable automated phone tree maze. The labyrinth is haunted not by a minotaur but by a smug robot voice asking you to key in or verbally say the patient’s name, date of birth and member ID number in various combinations. “Sorry, I didn’t get that,” you will hear the auto-voice say over and over as you feel your blood pressure rising.

I’ve found the best way to deal with it is to make my own voice as robotic as possible. I take deep breaths and empty my mind. I pretend that I, too, am a robot. Robots don’t care about being on hold for 25 minutes. Robots don’t think about how terrible our health care system is. Robot secretary has one goal: Retrieve numerical code that will enable patient to obtain vital test.

I don’t know if the companies deliberately bought the worst phone software ever made or if they bought the cheapest one they could find, and it just so happened to be the worst phone software system in the world. Getting through the automated system will take no fewer than 10 minutes. Usually more. Then you get put on hold. Your time on hold will generally vary, but it’s usually plenty of time to take a bathroom break. I know because I’ve timed and tested it. Sometimes the connection cuts out and you get hung up on for no good reason. At that point, it will take all your considerable willpower not to scream and cause a panic in the office. But you’ll want to scream. Oh, you will want to.

After you scythe your way through the bushes of the phone tree, you get a live person on the phone. Some of them deserve the title of “customer service agent.” Many do not. Often, the person you end up talking to is clearly in an overseas call center, and judging from the quality of the connection, possibly talking through a tin can on the end of a string. What I do know is, at this point in the process, they are not a medical professional. They are a little customer service robot just like me. They ask for the CPT code for the test or procedure. I tell them. They ask for the ICD-10 diagnosis code. I give it to them. Then they – well, I don’t know what they do at this point, exactly. I assume they use some sort of computer program to tell me whether or not the company is approving whatever the doctor ordered, but I don’t know exactly. It’s opaque. For all we know they could be flipping a coin. Sometimes the verdict is good, and I get the code that indicates an authorization. (This code does not indicate that the insurance company will pay the bill in full once they get it, but that’s another bucket of worms.)

If they deny the authorization, then I ask if there is someone else I can speak to. Sometimes they transfer me to the on-duty nurse person, who is always very nice and goes over the patient’s information – what the doctor ordered, why, symptoms, previously done tests. Mostly, though, the next step is a “peer to peer.” That is when the doctor who has ordered the test talks to a doctor employed by the insurance company and persuades them, using their most charming medical lingo, that the test is necessary for the health of their patient. Peer-to-peers are the second worst outcome of the prior auth process (the worst being, of course, the insurance company denies authorization with no recourse whatsoever). This is because our doctors are incredibly busy and scheduled to the gills, and asking them to take time away from literally saving lives to try to convince a bureaucrat that what they ordered is necessary is a waste of time and an insult to their medical education to boot.

You know what insurance program doesn’t generally require prior authorizations? Medicare.

Victoria Hugo-Vidal is a Maine millennial. She can be contacted at:
[email protected]
Twitter: @mainemillennial


Only subscribers are eligible to post comments. Please subscribe or login to participate in the conversation. Here’s why.

Use the form below to reset your password. When you've submitted your account email, we will send an email with a reset code.