JP Bader

Case Study: Doctors don’t always remember what’s best.

Amy has been an avid tennis player her whole life. After a particularly intense match she finds her right shoulder is hurting her. Like many women in their 30’s, she puts off doctor appointments until absolutely necessary because of work and family obligations. Instead, she opts to take a week off from tennis, and rest and ice her shoulder.

After a week her arm still hurts. Missing tennis is enough motivation to go to a doctor, so Amy can get back on the court. Luckily she is able to schedule an appointment during her lunch break. Impressed by her doctor, who specializes in sports medicine, Amy knows her doctor is very experienced and has treated many similar injuries.

After discussing the symptoms and reviewing an x-ray taken in the office, her doctor says Amy most likely has a rotator cuff tear and should receive an MRI to confirm. A rotator cuff tear sounds bad but Amy is happy to get an MRI to be sure. She leaves with an order and the contact information of a nearby imaging center. Amy calls to schedule her appointment immediately, and is able to get in that weekend. She’s thrilled that her injury will be taken care of before summer gets into full swing.

Friday afternoon Amy receives a call from the imaging center. They tell Amy her appointment might be canceled because her insurance will not authorize her procedure!

Amy is confused because she has a PPO plan, so she should be able to go anywhere in-network. She’s never needed pre-authorization before! When her doctor told her to do something, Amy could just go do it. Amy calls her doctor immediately, but the office is already closed for the weekend. She spends her weekend researching pre-authorizations online, and now is more confused than before. Why had her doctor not mentioned pre-authorization, and more importantly, why does her insurance company think the MRI is medically unnecessary?

Finally Amy is able to speak to her doctor on Tuesday. The doctor informs Amy that her insurance company requires 4 weeks of physical therapy before she can receive the MRI. The doctor admits unfamiliarity with Amy's insurance requirements, but, "most of the time patients are able to receive their MRIs." In the doctor's mind, this was a one-off case, and didn't think about possible delays due to a need for physical therapy. Most of the time, the doctor is used to getting the MRI stat.

Amy is irritated to have to go through physical therapy before knowing for sure what the problem is, but she is even more upset over all the confusion. Why didn’t her doctor warn her that she may not be able to get the MRI? Couldn’t the doctor find out when the order was written, so she could have canceled her MRI and started physical therapy sooner?

Your patients might not understand their insurance plans, but they hope you do

Very few patients fully understand every detail of their health plans because they are confusing and information is not easily available. Next Health Choice provides physician and their staff a simple, straightforward way to find the answers to the questions patients don’t even know they should be asking. Our service provides a clear answer to the questions for insurance plans, regardless if they require pre-authorization or not, for a service. Our system knows what criteria is needed per specific payer. Be an ally to your patient without adding work for your staff. Next Health Choice cuts through the confusion, so everyone else can focus on healing.


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