The Pre-Authorization Story
Once upon a time, a practice could forget to get a pre-authorization or maybe exceed the scope or maybe even provide the pre-authorized service on a different day and the carriers would allow for retro-authorizations so the claim would be paid. Fast forward to today and the insurance carriers are not so forgiving. Many take the position that you didn’t follow the rules so too bad you just provided the care for free.
Insurance verification and pre-authorizations are a vital part of your practice. A large percentage of denials are due to missing pre-authorizations or pre-authorization errors. A patient should never be scheduled for services until benefits are verified and pre-authorizations are in hand.
What is a pre-authorization?
There are many terms used for pre-authorization such as, “prior authorization”, “pre-certification”, “prior approval” etc. Though these terms vary slightly, the process they refer to is all the same. It’s a process where healthcare professionals are supposed to request confirmation from the insurance company that they will cover the prescribed medication, service, or treatment for the patients.
A pre-authorization is not a referral, and a referral is not a pre-authorization. A referral is generated by the primary care physician when referring to a specialist. Several insurance companies require that a patient have such a referral prior to seeing the specialist. The referral is only for the consultation. The specialist must obtain a pre-authorization for additional services.
But what if we didn’t get pre-authorization?
Fighters have a saying, “don’t leave the decision up to the referee”? That means they want to win decisively. They don’t want to leave any doubt as to who won. The same holds true for pre-authorizations.
If you forgot to get one, didn’t know you needed one, or thought you could get it after the service date, or maybe submitted the wrong date or CPT you have left the decision with the carrier. The decision to issue retro-authorizations now depends on the insurance carrier’s policies.
Once the insurance carrier denies the retro-authorization there is no recourse, and the healthcare provider has rendered the care for free. And, in some cases, your contract with the carrier prohibits you from billing the patient directly.
How to get a pre-authorization
A frustrating fact is that there are no standards that dictate how one goes about obtaining a pre-authorization. The process varies from carrier to carrier and even state to state. But there are some general guidelines.
Gather all the necessary documentation to support the service. This will include what the healthcare provider believes will be the next course of action and the rationale behind the treatment plan.
Pre-Authorizations are given for specific services on specific dates so make sure you have accurate CPT codes and know the dates of service. Even the slightest mistake will result in denied services.
Contact the insurance carrier and they will instruct you on how to submit the pre-authorization request.
It can take up to 10 business days to approve or deny the pre-authorization. If the request is complete and is included in the patient’s plan, then an authorization number will be given.
This authorization number must be included on the claim so the claim will be paid.
Whatever you do don’t take the verbal approval of an insurance employee. Always, always get a pre-authorization number. Yes, this process is time-consuming but if done consistently and accurately your claims will be paid.