Is it difficult for some doctors to figure out certain health insurance policies?

My health insurance company told me that they cover hearing aids over a certain amount if a doctor tells them it’s medically necessary. What’s medically necessary mean? They tell me that my doctor should know.

I went to an audiologist and asked her to find out. Apparently she is having trouble figuring out what the policy is. Her story is that her phone calls are not being returned, and she wants me to call my insurance company and try to figure things out myself. Is this possible? Can insurance companies be so obtuse that a doctor would have trouble figuring out their policies?

And if it is possible, does anyone have any tips on how I can figure out my insurance policy?

Each side seems to be telling me to ask the other side. My guess is that one of them is being disingenuous.

I’ve only been able to get my insurance company to tell me if they’re for sure going to pay for something once, and that was when I got the manufacturer of the device to contact my insurance company on my behalf. I’m not sure if hearing aid companies will do that or not, but it’s worth a try.

Other than that, the best I’ve ever been able to get is what you already have - “it should be covered if it’s medically necessary”, and “medically necessary” seems to be something that the insurance company decides, not your doctor. They don’t say for sure whether or not something is covered until it’s purchased and submitted to them.

It’s very frustrating, especially when considering big ticket items.

Some doctors are MUCH better at this than others. I had a dentist who knew every single bit of my dental plans (and I had four different ones in the years I was with him) by heart.

Some doctors are just downright hostile to any additonal work. They have THEIR rules and you follow it to the letter.

My current doctor is so accomodating since he knows I have no insurance, he has gone through hoops getting me the best deals with drugs.

But some doctors and techs etc are just lazy. Especially if they have enough patients already.

There is no reason why you shouldn’t be able to talk to customer service and explain, you may need a test done and you want to see if it’ll be covered before you doctor orders it. I’ve done this before, and they’ve never had them give me grief. My plans were Humana, Unicare and Blue Cross (Illinois) HMOs.

What exactly do they tell you? Do they give you a guarantee that something will be covered? I’m curious, because the best mine will ever tell me is “it should be covered if it’s medically necessary” and they won’t define “medically necessary.”

Lots of physicians are in my family, and I’ve worked in one’s office. Half of my job was waiting and calling to get insurance approval for surgery. But that has to come from the physician’s office; everything else is your responsibility. Bottom line is, though, that you should know what your own benefits are, no matter what. If you need help, the secretary or office manager should be able to help you get started, but they generally don’t know what your policy involves - there are literally hundreds, even under the same general name - UPMC PPO (small business) is different than UPMC PPO, even if they have the exact same co-pays written on the front.

Most places I’ve gone (for my own care) have a policy at the window or that you sign, stating that all charges your insurance don’t cover are yours, period. If you don’t have insurance, this doesn’t apply, but it does for everyone else.

Medically necessary is tricky. An example would be my wisdom teeth. They definitely had to come out, and soon - two were coming up (and visible), and two more would have wrecked my ortho work. What does my oral surgeon do? He submits to my insurance company that two are fully grown in and the other two are “impacted”. After surgery, who’s to know if they’re impacted or not, right? Had he waited till they were impacted, I would have needed braces again, without a doubt. Of course, my insurance wouldn’t have picked up the tab for that, now would they? :rolleyes: In that case, it definitely pays for your physician to know what “medically necessary” means, and how to accommodate the definition to work for his/her patients.