R. Daniel Bohl, Urologist

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Precertification: My Experience

I’ve been practicing medicine for a long time: over 50 years. Precertification didn’t always exist. But neither did insurance companies.

Precertification is a process by which a patient’s insurance company requires that the treating physician contact the insurance carrier and explain the reason for the desired test or procedure. The insurance carrier then has the authority to approve or deny payment for the requested service.

The stated goal of precertification was to avoid unnecessary or inappropriate tests and procedures. This was always a lie. The goal of precertification has always been to improve profits for the insurance industry.

In the early days, insurance carriers usually accepted the requests. Over the years, denials have become more aggressive and even consistent. Additionally, the list of tests and procedures requiring precertification has greatly expanded.

Here is my experience with precertification:

1. The physician determines that a patient needs a procedure that is on the precertification list for their insurance company, perhaps a CAT scan.

2. A staff member employed by the physician attempts to pre-certify the test by communicating with a relatively untrained employee of the insurance carrier. This staff member probably has a list of diagnoses or situations that are approvable, but there is also an expectation that the insurance staff will initially deny a percentage of requests. A straightforward request based on the insurance carrier algorithm might be approved by the insurance staff.

3. The physician’s office will generally object to a denial. At this time the physician will be required to talk directly with the relatively untrained insurance carrier employee.

4. The insurance employee will ask the physician a series of routine questions. The insurance staff already has answers to these questions, so the intention and result is to discourage the physician by wasting as much time as possible.

5. After answering all questions, the physician is placed on “hold” while a nurse working for the insurance company comes on the line. The nurse asks the same questions and gets the same answers wasting more physician time.

6. Next, the busy physician is referred to a physician who works for the insurance company. This is usually an older physician who has no real understanding of the specialized medical field and no real understanding of the patient’s needs.

7. After a comprehensive explanation to the insurance company physician, the requested test or procedure is almost always approved. I have never had a requested test or procedure not eventually approved, but my wasted time can easily be 30 minutes for a single approval. The obvious intent is to discourage me from ordering needed tests and procedures. Precertification can easily take more time than patient care, and I am paid nothing for this time.

What is the solution to this problem?

• Physicians could refuse insurance company contracts that require precertification. This would be effective only if a high majority of physicians participated.

• Because large healthcare institutions currently employ most physicians, the institutions could decline contracts that require precertification. As these institutions consolidate, increasing their market power, this is a realistic possibility.

• Legislation could make precertification contracts illegal. Although an option, this seems unlikely. Elected officials are corrupted by large contributions from the insurance industry. Beyond that, increased regulation has consistently harmed physician productivity rather than improving patient care.

• Physicians could simply refuse to accept any insurance contract. Although challenging, this is a realistic option. As the shortage of medical and surgical specialists worsens, patients will have no realistic alternative to seeking care from whatever physician is available. Once again, our government is an enemy of the people in this situation. The federal requirement for having health insurance under threat of a penalty means that patients would be paying twice for care were they to see an out-of-network physician. The government is subsidizing a corrupt insurance industry by this requirement.

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