Maybe you should call the physician’s office, if you think the test is wrong to ask if another test might be better, or give your referals a little written or oral education. I’m sure that most would appreciate it.

Is that like when a patient “wants” a routine chest x-ray to screen for malignancy and you write “cough” on the prescription so insurance pays for it? This type of behavior – circumventing the insurance companies – has a name. It’s called insurance fraud and it’s illegal. It’s also a million dollar problem for insurance companies who – yes, it’s true – need to make a profit. In response, insurance companies tighten the purse strings and what you end up with is a vicious cycle. While insurance companies are far from perfect, they are occasionally correct, and that CT scan you want to order isn’t actually justified based on empirical data. As a radiologist I see inappropriate studies ordered all the time – some of which actually get through the insurance pre-certification screen. It’s not only defensive medicine. There are plenty of instances where the completely wrong test is ordered (ultrasound of the abdomen and pelvis in a male patient with LLQ pain – it’s more common than you think). Insurance companies can be arbitrary, greedy and unfair, but the next time an insurance company denies your request for an expensive scan, consider that they may have a legitimate concern (particularly when we’ve recently learned that 30% of studies are unnecessary).

When I started practice, in the 1980’s, insurance would not pay for many outpatient procedures at all. If someone just wanted a physical with lab, etc. we would admit them to the hospital for a couple of days. That way everybody got paid. The powers-that-be finally wised up.

I think we all suspect that one reason for pre-certification denials is insurance’s hope that if they give us enough trouble and hoops to go through, we will say forget it, not worth the trouble. (Then we get sued for not being “persuasive enough”).

Sending them to the ER is really the only option now. Maybe patients will complain to their providers. Who knows? That, along with the needless extra cost, might make them wise up again some day.