Insurance problem

[Phoenixgirl]

My RTKR is scheduled for 2/29 and my insurance utilization management dept. has only approved me for the one night in the hospital. They said they would need to see my clinicals from the surgery to approve more. This seems outrageous. Last time I was there 3 nights. Have others had this problem? Or is it routine? Thanks for any info or ideas!

Bridget

 

[Jamie]

Bridget, I know this is unsettling, but it's pretty common for insurance companies to only approve a minimum number of nights initially. Give your surgeon's office a call and have them reassure you that your doctor will ensure that you are not released before you are ready.

For one thing, you must be able to walk, go to the bathroom and do stairs before you can be released. It is not likely you'd be able to do that after only one night!

But it will ease your mind to hear this from your doctor's office. So make the call.

 

[referee54]

Jamie is right on the money here---contact your OS's office and let them know---they have quite a bit of knowledge in how to handle this.

They will help reassure you and help you with this issue.

 

[Josephine]

Geese! That would seriously unhinge me! :DOH:

 

[kneeper]

Good grief. I agree that you should clue in your OS's office. It could be that they're very used to this company and as Jamie says do new authorizations after the first day.

 

[Phoenixgirl]

Thanks so much for the reassurance everyone! You were right. After my OS office faxed more info, the insurance was approved for two additional nights!
I feel much better now.

Bridget

 

[kfriedm]

I'm still waiting to hear from utilization management myself for my tkr in May. Silly me, I thought the decision would be either yes we will approve it or no, we won't approve it. Now I have to worry that the decision will be yes, we will approve it but only for ..... (!)

 

[Jamie]

Insurance companies don't give blanket approvals. They rightfully watch the number of days in the hospital as it is expensive. BUT....it is usually easy for the doctors to obtain approval for pretty much whatever they want. They have staff trained in how to work with the various insuance companies and it usually is not a problem.

For example, when I had my cardiac ablation last September, I had to go in the day before for a test that required me to be put under while it was done. That required an IV and my poor little veins are really hard to poke with IVs! The norm was to do the test, send you home after the 2 hours in recovery and then you come back the next morning for the ablation. That would have meant TWO IV sticks. When I told my surgeon that was worrying me, he was able to get approval immediately for me to just stay overnight in the hospital. What a relief for me. I was much less stressed and only one IV poke. So.....the doctors do have all this worked out.

 

[MapMaker53]

Most if not all doctors know how to play the insurance game. According to my health insurance provider, my bilateral MUAs had to be as an out-patient but my doctor wanted me in the hospital overnight on the cpm machine. Turns out, as long as my hospital stay was no more than 23 hours, I was considered an out-patient by my insurance. I got an overnight hospital room, but technically (on paper) I had not been officially admitted according the insurance company's definition. I'm sure each insurance company has it's own rules and definitions, so it's best to work with your physician's office and make sure they get all procedures and hospital stays pre-approved by your insurance company. At least that is how it is here in the U.S.

 

[Jamie]

MapMaker, you are absolutely right. Doctors frequently use that 23 hour rule skillfully to get a patient some needed hospital time and still have it covered under the rules of the policy. It's frequentlly used when someone goes into the ER with a problem so they can be observed over some time. Most hospitals even have a special small wing for these short-term patients so they aren't mixed in with the general population.