Wiki Procedure done even though it was authorized

[sbarbour3]

So my provider performed a surgery on a patient after only 1 code was approved. CPT code 11042 was denied and no authorization was given for it. The doctor performed it anyway, stating it was necessary. My office manager is saying that the insurance company is obligated to pay for that because it was medically necessary even though it was denied in the authorization process. What does everyone else think? Has anyone experienced this before?

 

[catherinetinkey@entmedicalservices.org]

The procedure still should be submitted if it was done regardless of the prior authorization. If the code was on the original prior authorization request and denied insurance won't pay for it. Most PA authorization denials, a letter is sent to the patient stating that if they decide to proceed they will be responsible for the cost. Most PA denials are because the patient hasn't met the criteria set forth by the insurance company for the procedure. The physician may think it's medically necessary but if all the criteria is not met insurance will deny for not being medically necessary because criteria was not met. If it wasn't on the original prior authorization request you can try to get a retro authorization or appeal the "not medically necessary" denial.

 

[CBLENNIE]

Most PA authorization denials, a letter is sent to the patient stating that if they decide to proceed they will be responsible for the cost.

When a provider is contracted (in-network) with a patient’s health plan, financial liability for services rendered without an approved prior authorization (PA) may fall on the provider. This is because the provider proceeded with delivering a service they were aware would not be covered, based on the denied PA request.

Responsibility for such denials is typically governed by the terms outlined in the provider’s contract with the health plan. For example, under our health plan’s provider agreements, these scenarios are generally considered provider liability and not the patient’s financial responsibility.

 

[amyjph]

My first question is always, was it coded correctly? I was also wondering what the case was? Is it podiatry? What was being debrided, where was the wound or ulcer? Has this been a repeated wound care over time?
As stated above, if you attempt to get auth and the auth is denied, you aren't going to get it covered if you proceed anyway. I think we need a little more info on it.
You could try to appeal it if you can demonstrate medical necessity or some kind of error or omission during the auth process. Might not work though.