September 22, 2011
Question:
Jennifer,
For a number of third party payors I participate with my office is required to confirm pre-authorization for certain services, which recently has required submission of medical records. After we receive pre-authorization and the authorized services are provided, we are denied payment. How can this be?
Thanks,
Dr. K
Answer:
The pre-authorization hurdle is another administrative obstacle we are seeing insurers use to complicate and frustrate the billing process. While obtaining pre-authorization seems to indicate you are in fact providing an “authorized”service, this not the case. In fact, the insurer is treating the service rendered as “authorized” only so long as the documentation noted concurrently for that service satisfies all documentation requirements. So, the fact that you received pre-approval, does not, in the insurers eyes, deem the service rendered automatically payable. On the contrary, many services our office is seeing challenged in audits or recoupment efforts initiated by insurers are for those services that also require pre-authorization. Reason being, those services may have an indicated a pattern of abuse in the past, or may have more stringent requirements to meet documentation and medical necessity standards, so the insurer is creating an additional trap prior to reimbursing.
The advice I have for you not to fall within the “pre-auth” approval, post-service denial is to remain vigilant with regards to documentation, payor policy and coding modifications. Also, you may want to take preventative action by consulting with a coding expert to review your documentation processes.
On a bigger scale, it is obvious that we need a legislative overhaul with regards to a healthcare practitioner’s right to reimbursement, and protections in the payor process.
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Comments on Pre-authorization received, payment denied
Jennifer,
In addition, after the service is “authorized”, and as you will hear from the representative’s disclaimer, the patient’s benefits may be in effect today, when the authorization is given, but not in effect tomorrow or next week when the actual service is rendered. It is important to have a tight patient payment billing policy that the patient signs off on that indicates they are ultimately responsible if they are no longer insured.
Yours in compliant maximized billing,
Barry
Barry Haitoff, CEO
Medical Management Corporation of America
(845) 363-4833
(888) 323-8823×4833
bhaitoff@mmcoa.com
http://www.mmcoa.com
*******************************************
Jennifer,
The concept of pre-authorization should be to confirm insurance coverage and stipulate that intended procedures are covered within the policy. Unfortunately, that is not the case. The insurance companies are in fact paying outside sources to handle the pre-authorization process and the goal is a denial of services. Furthermore, all carriers stipulate that pre-auth approval is not a guarantee of payment. The only financial protection for the physician is to have the patient sign a document personally guaranteeing payment if the coverage is denied. It is also important to note that if the authorization process has to go into appeal any subsequent approval is as if the date of approval; not the date of request or possibly the date of the procedure. If the procedure is done prior to the date of approval, the carrier will not pay.
At MMS we work with our clients on a continuous basis to avoid the pitfalls that insurance companies use to avoid payments. There are two other important factors that the physicians need to keep in mind. First, the authorizing companies try to apply their own rules which are not necessarily in compliance with the carrier’s rules; so be sure to check your contracts. Second, whenever possible book procedures at least a week or ten days ahead to allow for any appeals process.
Terry Spector COO
Madonna Management Services
375 N. Broadway LL2
Jericho N.Y. 11753
516 433-5018
516 241-9349 cell
tspector@mmsgroup.biz
Dear Jennifer,
I read with interest the articles regarding pre-authorization and subsequent denial. I can’t begin to tell you how many times this happens in my practice (general surgery). Try re-possessing an operation that has already been performed. In addition, when the insurer denies the claim for service, it gets denied across the board–surgeon, hospital, anesthesia. My experience is that it can take as long as six months for resolution.
Tactics that my office uses that seem to work: 1. Contacting the NY State Insurance Commission. 2. Threatening the insurer with calling the NY Times and exposing them. We have been doing this alot lately, and it actually works. The insurers appear to be taking the threat of negative press seriously. Usually within a few hours of my issuing the threat, my office will get a call from a supervisor at the insurer telling us that the claim has been reprocessed. They then want a guarantee that we will not contact the press. The biggest offenders are (in order): Oxford, HIP, and Blue Cross.
Thank you for spreading the word. You continue to provide excellent information and insight into many of the problems plaguing physicians today.
Sincerely,
PS MD, FACS