Prior authorization. What is it and why does it take so long?
My dad is in a Medicaid adult foster care home in Hawaii. His condition has declined and he needs a higher level of care. I’ve found a nice nursing home near his family. I’m in regular contact with the nursing home. They have room and will accept him. All they need is ‘prior authorization’ and he can be transferred.
This is where the nightmare begins.
The insurance company says his current case management agency must file the paperwork to request prior authorization. The case management agency says they do not request it. The nursing home says the case management agency must do it.
This finger pointing started in early March. No progress has been made.
The case management agency makes all sorts of excuses: it’s not their job; they already sent the paperwork in April, they are doing it soon; the nursing home fax number is wrong, they forgot, the person who does it is sick. It’s goes on and on like this.
In desperation I called APS yesterday. They said it’s not an issue they deal with.
The nursing home has been helpful (I think). The insurance company has been helpful (I think).
What should I do? I don’t know where to go for help. Can anyone shine some light on this for me?
4 Answers
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The doctor(s) must order the nursing home care. imo.
I would call the insurance company and tell them they can just continue to pay the emergency care, but that doesn't sound right, does it? So, maybe don't do that.
Next time, or now, call 911 to take him to the E.R., who can/and will discharge him to the NH. Telling them that it would be an unsafe discharge to release him to the care home because he needs a higher level of care.
I am convinced that "Prior Authorization" is the system's way of NOT paying for needed care. A way to commit fraud, deny and delay needed health care, and payment.
There is no realistic way anyone could navigate the system, especially when they are ill.
For example, I had prior authorization, but delayed getting the actual appointment due to Covid. And there would be no appointment until
about a 3 month wait. So, when I did call for the appointment, they would not schedule it, saying: Well, the authorization is still in effect, BUT there is no way we can get you in before the authorization expires. (Believe it or not!) So, I am not getting treated.
Maybe someone will be able to give you a viable solution. I just wanted you to know you are not alone, and doing a good job of trying to make this happen for your father. No guilt.
Can you contact an ombudsperson in your state? Someone might have some insight into these particular companies and how to get through to accomplish something.
An alternative is to do some research, find out who the top execs are, and contact them. You might also ask if they have their own ombudsman, as you're certainly not getting the responses you deserve. Being aggressive and sometimes manipulative, I would also observe casually that the companies certainly aren't displaying consideration for their clients, and that perhaps it's time to replace them with companies that are.
Although I've never done this, it seems though that using social media to highlight a company's deficiencies sometimes gets result, as does contacting a local tv station; I think they thrive on feeling they're identifying glitches and creating a positive response while helping someone in need.
Good luck; sometimes these journeys can be so frustrating, for reasons well beyond health issues.