Per the corporate medical policy
If you are considering undergoing an expensive medical procedure such as an MRI or a neuropsychological evaluation, be very careful when the insurance company states that the service will be covered 100% “per the corporate medical policy.” Those five words are they key…per the corporate medical policy. When patients hear this, they tend to think that this means the medical procedure will be paid in full and proceed with the evaluation. What is actually means is that a decision to pay for the service will not be made by the insurance company until after the evaluation takes place. What this often translates into is the insurance company finding every reason in the world not to pay for the service.
As an example, I was once evaluated a child who suffered a brain injury four years prior to the evaluation. There was a question as to whether the brain injury affected his development. The insurance company stated ahead of time that the service would be covered 100% per the corporate medical policy. The evaluation was completed and then the insurance company refused to pay because they said the brain injury occurred too long ago. This is frustrating because this information (the date of the brain injury) was well known in advance and the insurance company could have easily made a determination beforehand. Instead, the patient’s family was told they would need to pay thousands of dollars for the service, which they cannot afford.
Given the above, my advice is as follows. Press the insurance company to provide something in writing saying that the procedure is pre-authorized or not pre-authorized. If the company refuses, you may want to consider switching insurance companies at some point. Make sure the words “per the corporate medical policy” are not included because this only serves as a way for the insurance company to wiggle out of not paying. Secondly, be sure to appeal such cases to the insurance company. If that does not work, contact your state insurance committee. Insurance companies do not like to be bothered by state regulators. If \ this does not work, contact your local congressperson and have that individual call the insurance company on your behalf. You would not believe how effective this can be. Remember, the insurance company needs the help of lawmakers to pursue their agendas and does not want to make any legislative enemies. If the local congressperson does not work, call your state U.S. senator.
As an example, I was once evaluated a child who suffered a brain injury four years prior to the evaluation. There was a question as to whether the brain injury affected his development. The insurance company stated ahead of time that the service would be covered 100% per the corporate medical policy. The evaluation was completed and then the insurance company refused to pay because they said the brain injury occurred too long ago. This is frustrating because this information (the date of the brain injury) was well known in advance and the insurance company could have easily made a determination beforehand. Instead, the patient’s family was told they would need to pay thousands of dollars for the service, which they cannot afford.
Given the above, my advice is as follows. Press the insurance company to provide something in writing saying that the procedure is pre-authorized or not pre-authorized. If the company refuses, you may want to consider switching insurance companies at some point. Make sure the words “per the corporate medical policy” are not included because this only serves as a way for the insurance company to wiggle out of not paying. Secondly, be sure to appeal such cases to the insurance company. If that does not work, contact your state insurance committee. Insurance companies do not like to be bothered by state regulators. If \ this does not work, contact your local congressperson and have that individual call the insurance company on your behalf. You would not believe how effective this can be. Remember, the insurance company needs the help of lawmakers to pursue their agendas and does not want to make any legislative enemies. If the local congressperson does not work, call your state U.S. senator.


