Practice Management Alert

Reader Question: Our orthopedic practice obtained prior authorization from a patient’s Medicare Advantage (MA) plan for an outpatient knee MRI. The study was performed within the approved period, but the plan denied the claim as not medically necessary because the record did not show six weeks of conservative treatment. May we bill the patient or should we appeal?

Illinois Subscriber

Answer: You should submit an appeal before billing the patient. Remember, prior authorization shows that the payer reviewed the service before it was performed, but receiving prior authorization is not a payment guarantee. For most payers, coverage may still depend on eligibility, benefits, coding, medical necessity, timely filing, and whether the service matches the approved request.

If you’re looking for conservative treatment recommendations in the record that the initial claim might have missed, look, for example, for mentions of activity modification, rest, ice, compression, elevation, anti-inflammatory medication, bracing, a home exercise program, or physical therapy.

From there, you can build the appeal. Confirm the denial reason, the plan’s medical necessity policy, and the reconsideration deadline. Compare the claim with the authorization, including the patient, provider, service location, procedure, diagnosis, units, and date of service. Submit the authorization record, denial notice, order, relevant notes, conservative treatment history, diagnostic findings, and a concise letter tying the documentation to each coverage criterion.

Don’t add or backdate documentation — a clinician may clarify an incomplete record only when recording care that actually occurred.

Tip: The Centers for Medicare & Medicaid Services (CMS) requires impacted payers to give a specific reason when denying prior authorization requests for non-drug items and services. Organize the appeal around that reason instead of resending the entire chart without explanation. For more information, see the CMS Interoperability and Prior Authorization Final Rule.

It may be best practice to wait to bill a patient when a claim is denied. In this situation, you should review the remittance advice, contract, plan rules, and any advance notice or financial consent document — authorization does not establish patient liability. Just keep the patient’s account on hold until, and unless, you find confirmation that you can transfer the balance.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC