The process of getting an MRI for a patient used to involve two things - a doctor who wanted an MRI and a patient who needed an MRI. A doctor is trained for over 11 years (many specialists are trained even longer) to make the right decisions on behalf of patients. We use that knowledge and training to decide when an MRI makes sense for our particular patient’s situation. However, in the past decade or two things have changed drastically and continues to become progressively more complex. Now getting an MRI involves:
When a patient needs an MRI, first the doctor (or his or her staff) has to figure out which third party administrator is used by the patient’s particular insurance company. Once that is determined, the doc has to reach out by phone or submit an online form to request the test. This includes coming up with special codes for the test, the diagnosis, and explaining everything that has already “been tried” for the patient (i.e. visits, therapy, meds, etc.). Once submitted, this request undergoes review. Somewhere around 75% of the time it is rejected or denied for one reason or another (usually an administrative burden - i.e. the patient’s visit date was not entered or the patient’s physical therapy wasn’t submitted correctly, etc.). Often, the doctor has to then call in and wait on hold for 10-30 minutes to speak with someone who is clinically trained (up until this point the doctor is talking only to non-clinical administrative staff) to argue the patient’s case as to why their patient needs THIS test NOW. Once that is all finally completed, an approval is usually given. In other words, most of the time, these hoops are just hoops, created by insurance companies and third parties for doctors and their staff to jump through, so that maybe some will just back out of the hoops and not jump. I.e. the insurers will save money because some offices just can’t persist long enough to get the approval. Which means, some patients who need a test, have to go back to the drawing board and start over - often meaning seeing a specialist for evaluation so that THEY can try to get the approval. At DPC practices, like Direct Doctors, while we still have to fight these battles, we are better equipped to navigate this on behalf of our patients because we have more time and know our patients much better. We care to go that extra mile, even if it is a pain! We don’t let our patients’ needs fall through the cracks. To find out how else we practice primary care differently, check us out at www.directdoctors.org.
16 Comments
April wood
1/23/2021 12:37:35 am
What is meant by third party non clinical staff
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Tequila Walker
2/20/2021 12:08:21 pm
Is you have a MAN MADE DISEASE Such as MULTIPLE SCLEROSIS, why is it such a problem for your insurance (medicaid) to pay for MRI? Isn't that what insurance is for?
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Steve
7/9/2021 04:19:32 pm
Insurance companies are a big scam industry. The very second you make your monthly payment they take the money and invest it. They earn a lot of money on investments so they don't like to pay out claims. By the time you go to collect your money insurance companies have already made on average 3x on that money. Insurance companies making people wait days for surgery and thus causing increased damage should be in jail but insurance company lobbyists have corrupted our government. In short, when someone has a painful injury in America they are in a living hell caused by greedy insurance companies. Our prescription drug prices are the highest in the world due to what is best described as "the prescription drug mafia" but the official name is "pharmacy benefit groups". I live in America but I opt out of the American medical crime scene. To save a bundle I get my surgeries in Mexico and my prescription drugs from Canada. US doctors are the best but Canada and Mexico have worked just fine for me. US doctors unfortunately are stuck in a corrupt system.
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Peter
7/25/2021 05:50:36 am
Insurance companies are killing people and have the Congress in their pockets enabling them. If they can kill enough people before they reach 66 years of age, then hallelujah! One less person they don't have to pay social security or Medicare to. Our Government is greedy, self serving and corrupt! Why we Cheers these criminals on at conventions and primaries is beyond me.
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12/10/2021 07:26:32 pm
Thanks for pointing out that a doctor is trained for over eleven years to make the right decisions on behalf of patients. My husband hit his head on the floor last night when he slipped so this is helpful. We are hoping to find a medical facility on Monday that can provide an MRI scan with superior image quality at an affordable rate.
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5/26/2022 08:09:02 am
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5/30/2022 10:09:40 am
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2/4/2023 05:59:44 am
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2/4/2023 06:00:44 am
I always learn something new when reading your blog. Keep the great content coming
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2/4/2023 06:01:22 am
I appreciate the research and effort you put into creating this post. It shows in the quality of the content.
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2/4/2023 06:02:02 am
I love the way you present complex ideas in a simple and accessible manner. Great job
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AuthorLauren Hedde, DO; James Hedde, DO and Mark Turshen, MD are Family Physicians and Co- Founders of Direct Doctors, Inc. a Direct Primary Care Practice. Archives
February 2022
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