Precertifications

A brand new feature of our health plan this year is that everything has to be precertified. They didn’t actually tell us about this change until they started denying claims for not being precertified.

So a doctor wants to do a blood test or order an MRI or perform a procedure or prescribe a drug. First someone from the doctor’s office has to find the right way to request that Cigna approve whatever it is. Then Cigna asks for medical records. Eventually the doctor‘s office provides the medical records, and Cigna ponders them for a week. Then Cigna may approve the medical care, or may deny the medical care. If Cigna approves it, then you can move forward one space. If Cigna denies it, well, that’s because they care.

So what happens is that medical care grinds to a halt while Cigna does nothing useful.

From my perspective as a patient, this creates a number of unsolvable problems. I’m actually the one who cares about me getting medical care, but I cannot do anything in this entire process. I cannot ask Cigna to approve anything. I can ask the doctor’s office to start the precertification process, but I am not allowed to be kept in the loop about that process. I cannot get verifiable answers to whether or when the doctor’s office has requested precertification, whether or when Cigna has asked for medical records, whether or when the doctor’s office has provided those records, or whether or when Cigna has actually approved or denied the medical care. I am not notified at any step by anyone, and I cannot receive any written answer from Cigna about any of this process. Cigna’s answers over the phone about precertifications are erratic/random/untethered to reality/completely at odds with answers they may give five minutes earlier or later.

When I beg Cigna to expedite the process, Cigna replies that the doctor’s office has to do the begging. I’ve noticed that doctor’s offices don’t like to beg. They also don’t like to wait on hold, and I have actually seen surgeons waiting for an hour or longer on hold with Cigna.

Cigna will not provide their standards of care, their criteria for approval, or their reasons for denials. When Cigna substitutes their medical judgment for the medical judgment of my doctor, Cigna will not answer any questions or recommend any alternatives.

I’m supposed to have an MRI on Friday, June 20. We scheduled it last Friday, and the doctor’s office assured me last Friday that they would take care of the precertification in time. This evening Cigna said that they do not intend to decide on the precertification until late next week at the earliest. Under Cigna’s preferred timetable, even if they approve the MRI at that point, the MRI cannot happen until mid-July. If they deny the MRI, well, that’s because they care. At which point we have to start some miserable appeals process, or just go to the emergency room.

I had thought that a major concern of health care reform was trying to shift health care away from emergency rooms. Cigna’s precertification process does not apply to emergency rooms, so it pushes care towards emergency rooms.

Both Cigna and the doctor’s offices are able to speed things up somewhat if they treat them as emergencies, which they can only do if they wait until the last minute. So they wait until the last minute, playing chicken with each other. And doing it at the last minute means that we get to plan for an MRI on Friday (take time off work, arrange child care, cancel our other plans) without knowing until Friday whether there was any point in doing that.

And of course the doctor’s office cannot schedule a phone call with the PA about the MRI results until the MRI is completed. And they cannot schedule a follow-up appointment with the PA until the phone call is completed. And they cannot schedule an appointment to talk to the surgeon until the appointment with the PA is completed. And they cannot schedule surgery until the appointment with the surgeon is completed. Just like the precertifications have to be done last-minute, all of these appointments have to be made last-minute. The doctor’s office is entirely complicit in this refusal to allow patients to make any plans, in this refusal to acknowledge that many things in life are much easier with advance planning, and are painfully difficult without it.

It’s a degrading process, and a horrible way to treat people.

Update with a case study of this particular MRI:

We told the doctor’s office last Friday that they needed to start the precertification process. Cigna says today that no precertification request was made until the following Wednesday, two days before the MRI. We have no way to know whether the doctor’s office actually procrastinated that long.

The doctor’s office told us that they sent over all clinical information yesterday. Cigna told us last night that the doctor’s office had not sent over any clinical information. We have no way to know who is lying.

Precertifications might be handled by Cigna or by Medsolutions. Last night, Cigna said that Cigna was handling this precertification. This morning, Cigna said that Medsolutions was handling this precertification. Later this morning, Cigna said that Cigna was handling this precertification. We have no way to know which is true.

The doctor’s office told us this morning that they spoke to Cigna on the phone this morning. Cigna said later this morning that this would be how Cigna knows to escalate (speed up) the precertification, but that it didn’t happen. Cigna also says that they cannot take an escalation request from the patient or anyone other than the doctor’s office, and that they cannot call the doctor’s office to confirm that the request should be escalated. The doctor’s office refuses to call Cigna again until noon. Because proving that Cigna is a bunch of lying assholes is best accomplished through passive-aggressive hostility directed at the patient who is begging you for help.

The medical guidelines for approving a knee MRI that I could find from another insurance company say to approve it for basically any suspected or known knee injury, knee malfunction, or knee pain, because it’s the best hope for seeing what is going on in the knee. Cigna needs detailed medical records because, wait, no, they is absolutely nothing that could possibly be in anyone’s medical records that would suggest that a first MRI should not be approved.