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Preauthorization – Understanding Health Insurance, Part 2

 

Due to changing health care laws over the past couple years, the Reflex team has seen many health insurance companies change their requirements and coverage for Joint Fluid Therapy (HA Injections). Many insurance companies now require pre-approval or preauthorization before any practice can treat you.

Pre-authorization is an extra step that many insurance companies require for their plan members before they agree to pay for treatments at your regular co-insurance rate. Reasoning behind pre-authorization may vary but, generally, insurance companies require this step for quality assurance and cost control.

 

How do I get pre-authorized for joint fluid therapy?

Your first step is to schedule an evaluation.  We will measure changes in your mobility through a few basic functionality tests, perform a manual exam to note any physiological changes, and discuss the symptoms and pain you’re currently experiencing. They may also use X-ray or Ultrasound to for additional diagnostics. During this visit, your doctor will create chart notes detailing the current state of your knee health and why their recommendations for therapy.

Our office submits this paperwork from the visit to your insurance provider with the request for treatment based on the physician’s findings. Your insurance company will review this information to determine if they think it meets their previously established guidelines for coverage of joint fluid therapy.

They will notify both you and Reflex when the treatment request is approved or denied. If your treatment is approved, Reflex will contact you to schedule your next appointment. If the request is denied, we will automatically submit an appeal to the insurance company, asking them to reconsider approval for treatment. Sometimes this requires us to submit additional information and records, or have one of our physicians speak with an insurance appointed physician reviewer.

Why do insurance companies deny treatment?

An insurance company may deny your claim for one of three reasons:

  • The service isn’t covered by your policy.
  • The insurance company does not consider the requested service as medically appropriate/necessary.
  •  There was not enough information provided to approve the treatment.

This process can be frustrating for both patients and doctors offices. It can require an extra visit to the office by you, and additional paperwork and processing by the insurance department here at Reflex. We do everything we can to get your insurance policy to cover your treatments based on your plan and work hard to get you treatment when you need it.

 

How do I know if my insurance requires pre-authorization for Reflex treatments?

If you want to find out if your insurance company requires pre-authorization for our treatments, we encourage you to contact your provider directly. We offer a step-by-step guide on our website that explains how to check your coverage, with specific questions you can ask your insurance representative.

Although the process can be complicated, Reflex will work with you and your insurance company to provide you with the best treatments possible. Please call us if you have any questions.

At Reflex, we pride ourselves on being Portland’s knee pain experts. If you’re looking for relief, give us a call today at (503) 719-6783.