Do Doctors Review Insurance Before Ordering Tests? What to Expect When a Test is Not Covered

When a doctor decides to order a medical test, insurance coverage is often a key consideration. However, the primary factor in any decision is the medical necessity of the test for the patient's diagnosis and treatment. This article explores how doctors typically approach insurance review, the implications when a test is not covered, and what patients can expect.

Considering Insurance Coverage

Doctors generally take a patient's insurance coverage into account when ordering tests, especially if the tests are expensive or there are alternative options available. However, the primary driving factor in their decision is the medical necessity of the test for the patient's diagnosis and treatment. If a test is necessary for proper care, the doctor may proceed with it even if it is not covered by the patient's insurance.

When a Test is Not Covered

When a test is not covered by a patient's insurance, the doctor may still order it, particularly if it is deemed essential for the patient's care. In such cases, the patient is usually informed about the potential out-of-pocket costs. They may have the option to discuss alternatives or payment plans. The decision to proceed with a non-covered test ultimately depends on the patient's needs, the doctor's judgment, and the patient's willingness to bear the costs.

What Patients Can Expect

Physicians generally know whether a patient has coverage for clinical care, though they may not know all the specific details of the insurance plan. Sometimes, unexpected coverage issues can arise. Some tests require pre-authorization before they can be administered. In such cases, if the pre-authorization is not obtained, the test may still be ordered, but the provider may assume the financial responsibility.

The complexity of insurance plans and the myriad of labs and radiology services involved makes it challenging for medical offices to know all the specific coverage details. Therefore, doctors may order a test they believe is necessary and inform the patient that the facility will seek authorization for reimbursement. The patient is also informed about their potential co-pay.

Handling Non-Covered Tests

After the test is ordered, the office staff sends the request and insurance information to the testing service. The testing service handles the authorization and reimbursement process, taking into account their costs and charges. This process can be time-consuming, and it may take up to three hours to get approval. Given this, medical offices often prioritize other urgent matters and may not have the time to seek lengthy approvals.

Alternatively, patients may choose to pay for the test upfront and then handle the reimbursement with their insurance company. This can provide a more straightforward and timely solution, though it may require additional coordination and paperwork.

Conclusion

While insurance coverage is a critical factor in the decision to order a test, the primary consideration is always the medical necessity. When a test is not covered, the doctor and the patient make decisions based on the patient's needs, the doctor's judgment, and the potential financial impact. Understanding these processes can help patients better navigate their medical care and financial responsibilities.