Central PA Medicine - Summer 2017 - 4

daup h i n cm s .org

From the Editor

Prior
Authorizations
One More Reason To Be Angry
At Health Insurance Companies?

Heath Mackley, MD, FACRO
Central PA Medicine Editor-in-chief

facebook.com/dauphincms

Dauphin@pamedsoc.org

Dauphin County Medical Society
777 East Park Drive, PO Box 8820
Harrisburg, PA 17105

Summer 2017 Central PA Medicine

Don't you get
upset at health
insurance
companies?

The medical interventions are paid for out of a
pot of money that all members of the "premium
paying community" pay into. Like all communitarian arrangements, the labor of the healthy pay
for the medical interventions of those that need
them. The insurance company keeps a portion
of this money because of the services it provides.
To that frequently asked question, my short This includes: defining "medical necessity" for
answer is, "No."
the group, negotiating a lower "price" for the
medical interventions, following the laws that
I have no love for health insurance compa- regulate this financial product, and marketing
nies either, but the anger that physicians and the product to encourage new members to join
patients feel about them should probably be the "premium paying community."
more evenly distributed between the insurance
companies, the healthcare providers, the lawyers,
A key point is that the insurance company,
the government, and anyone that receives the whether it is a government agency or a corpobenefits. Like most of our modern "messes," it ration, defines medical necessity. There may
started with a mixture of theory, good intentions, be an appeal process, but the final decision is
self-interest, and lack of appreciation of the made by the insurance company. You may have
consequences of government policy decisions. legal recourse, and the court may intervene and
From that point, it evolved in directions that interpret your view of medical necessity as the
reflected the competing interests of the parties correct one, but other than that rare instance,
involved. But this is not going to be a historical the insurance company decides.
treatise about how we arrived to where we are.
Instead it's a description of where we are, so
You have no way of knowing ahead of time
we can best move forward with our eyes open. what the insurance company will approve
because their policies are not made available
Your insurance policy is a contract. Like to you. Furthermore, even if you did have that
me, you've probably never seen this contract. policy made available to you, those policies that
In my case, I'm not a party of this contract, it govern their decisions will continue to evolve.
is between the Hershey Medical Center and They have to. The scientific base of medicine
Highmark Blue Cross Blue Shield. However, continues to march on. The outcome of this is
the simplified core of the contract is that that you don't know "what the rules are," and it's
the insurance company will cover medically hard to envision a scenario where you ever will.
necessary medical interventions in exchange
for a premium. Both sides voluntarily enter
And this is why more and more medical
into this agreement, and I voluntarily signed interventions require pre-authorization. The
up for the benefit.
healthcare provider submits the prescription
of the physician or other health care provider,
and the insurance company gives an answer
of whether or not the prescription is medically

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Table of Contents for the Digital Edition of Central PA Medicine - Summer 2017