min read
Braden Mosley

Preventing Medicare horror stories: 3 ways to navigate prior authorization

Everyone has heard a healthcare horror story.

Someone close to you has probably been denied treatment, or even flat-out ignored, by an insurance company.

Here’s how I help my clients prevent these nightmares.

Read time:  3 minutes 42 seconds

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You've heard health insurance horror stories

I had a client who was turning 65 and was still on his employer group coverage.

After careful calculations, it was evident he'd potentially save thousands per year by switching to a Medicare Advantage plan.

He was thrilled!

Yet, at home, he quickly became entangled in the web of online misinformation surrounding prior authorization.

The click-bait headlines he read online prevented him from making the best logical decision.

“82-year-old woman denied by insurance!”

“Insurance Denies Lifesaving Treatment!”

"Insurance company... blah... evil... blah blah"

Unfortunately, most posts online do not help you understand the full scope of an issue and aren't written by licensed insurance professionals.

Even other trusted professionals, like doctors, don't fully understand the system.

The fact is, prior authorization is a process that allows insurance companies to use money more effectively so they can:

  1. Pass savings to their members
  2. Maintain a 3% profit margin

Today, I will explain prior authorization, including the good, bad, and ugly.

Then, I will share 3 ways you can prevent getting denied for medical procedures.

What is prior authorization?

Remember the last time you watched a sports game where the referee made a critical call?

That's exactly what prior authorization does in the healthcare system.

Just like a referee ensures fair play, prior authorization ensures insurance is not being abused.

You've likely heard stories of painting prior authorization in a less-than-favorable light - people being denied medication or procedures.

There are 3 important things you need to know to avoid denials:

  1. Trust your doctor
  2. Know your plan
  3. Ask the right questions

1. Trust your doctor

Prior authorization doesn't exist to make your life harder. It exists to pass savings to you.

Usually, in insurance, the more red tape there is, the more money you save.

So, when something is denied, it's simply a signal from the insurance company saying "We need to make sure this is legit... we can't waste money on potentially bogus claims because we pass savings to our members."

Once your doctor's office sends in the necessary documents, the procedure will be authorized.

If your doctor cuts corners or is committing fraud in any way, the claim may not be approved.

A Cancer doctor was recently incarcerated for billing $60 million to Medicare after diagnosing hundreds of patients with cancer who didn't actually have cancer.

Not only that... but he even treated them with chemo! 🤯

That is downright EVIL.

While this is very rare, it happens.

Prior authorization exists to stop cases like that.

2. Know your plan

There are 2 important things to understand about Advantage plans:

  1. Each one has a network (HMO or PPO)
  2. Each one deals with prior authorization differently

A. Networks - HMO vs PPO

HMO (Health Maintenance Organizations) are more restrictive. They tell you to stay in-network unless you get a formal prior authorization from your in-network doctor.

PPO (Preferred Provider Organizations) are more flexible. They allow you to go in and out of the network freely (even if you pay more money out of network.

Comparing plans from the same company, Prior Authorization will occur more on an HMO than a PPO.

B. The company matters

Some companies do in-house prior authorization from start to finish.

Others use a third-party company at first, then step in and act as the judge in special cases.

Some companies have millions of members.

others have thousands.

Some companies build their brand on consistency and reliability.

Others sell fancy bells and whistles with tons of annoying fine print.

These factors play a big role in how a company deals with prior authorizations.

When it's all said and done, you may experience fewer denials on one company's HMO than another company's PPO.

3. Ask the right questions

If you are afraid of being denied but want to save money on healthcare and enjoy extra perks, you need to ask your broker the right questions.

Make sure he or she knows:

  • Your primary doctor
  • Specialists you see regularly
  • Procedures coming soon
  • Your preferred hospital
  • Your list of medications
  • Your fears and concerns

A good broker will take notes and research these concerns.

They won't know off the top of their head who's in-network and who isn't.

They won't be able to tell you 100% there will never be denials.

But, they deal with these things every day and can go to bat for you if something goes South.

I do this for my clients, at least once per year, at no cost.

Click here to meet with me for free.

That’s all for today.

See you next week.

Braden Mosley

Licensed Insurance Broker

Midwest Insurance Group

When you are ready, here are 3 ways I can help you:

  1. Life, health, retirement consultation: If you have questions about insurance, 401k or IRA accounts, Social Security, or anything else related to retirement, meet with me at no cost and I will help you sort things out.
  2. Medicare Mastery Course (free): If Medicare feels confusing and overwhelming, I have condensed years of experience as a Medicare expert into a 53-minute course to help you melt away your Medicare worries. Includes a fill-in-the-blank workbook and 12 important resources you’ll need along throughout the Medicare process.
  3. Retirement Reimagined Journal: If you are feeling stressed about retirement in general, this journal contains 160 must-ask questions to help you gain peace of mind about your health, wealth, legal matters, and insurance. Go check it out on Amazon.
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