Wiki Claim denied for No Authorization

[orthobiller2017]

I have a question on a surgery denial. Prior to surgery i verified no preauth was required and got a call reference#. Procedure was outpatient so no alarm bells went off. Surgery was performed and billed. Surgery was denied for No preauth. I called and the claims rep was able to verify my previous call reference # and that I was given incorrect information. Recommended an appeal. I also called the medical mgmt dept and tried to get retoroauth. Medical mgmt dept at insurance reviewed and said initial rep did give me correct information and no auth was needed. Rep then was nice enough to do conference call with claims dept and told claims customer service claim should be processed. Got a reference # on that conference call. Despite that claims dept is still upholding the denial. Any recommendations? I understand if we didn't try at all but in this case I really did. Of note provider is Oon w/ insurance. On the calls we did tell both medical mgmt reps pre and post sx the providers status and CPT code

Also pt does have secondary insurance which did give us an auth. Should I bill secondary or wait till " resolution with primary"? Primary EOB currently states no pr resp if contracted which we are not.

Thank you!

 

[misslb21@yahoo.com]

When you called and were given the wrong information your call was recorded. With the call ref# they can review the tape. Don't ask them to review it, demand that they do it! It worked for me in the past when I was in the same position.
Good luck

 

[marthaarr@qwestoffice.net]

Rheum coder

We have had this same exact issue. And it seems to be a trend. We call for benefits prior to IV infusion and several times we have been given the "not PA or Pre D needed" In these cases I go straight to our provider rep (from that particular insurance company) so far that has worked for us. But this is a very troublesome issue that seems to happening more and more often.
If anyone else has had this issue, it would be great to hear their experience on how they handled the issue and if/how it was resolved.

Thanks,
Martha

 

[mschaller]

I've had this same issue, as well. Keep climbing the appeal chain, calling and asking for supervisors. Be firm and don't give up. If all else fails I would file a complaint to your state insurance commission. Being that you are OON with the insurance, it might be worth getting the patient involved and explaining he will be responsible if insurance doesn't pay. Sometimes the insurance responds better to a patient complaint that to the provider.

 

[JAMETH345]

We're having similar problems. Sometimes when we check benefits and eligibility we're told we DO need prior auth, but when we call for prior auth we're told it's not needed, so we do the procedure, and it gets denied for no prior auth. the problem is they refuse to provide anything in writing that the procedure doesn't need prior authorization, and when we call back with the reference number, we're told "no one told you that". it's very frustrating, and not fair to the patients. We're also out of network with most insurances. any tips on handling this would be appreciated.

John M., BS, CPC, CPB

 

[Victoria323]

Pre Auth

I always try and use a portal if its available and take a photo of the "no pre auth or review required" BUT if I can, I always ask "Is a pre determination available?" if so, I ask what policy they are reviewing it with. The nurse reviewer is usually going off a medical policy and knowing what they are looking for prior to submission is helpful. I think BCBS/Anthem is the shadiest group I call. I try and use the portal every chance I get with them, because they will try and get you to not do a PD then deny the claim for medical necessity.

 

[JCaillouet]

Only things I can advise:

1) Inform the patient and provider. If nothing else getting both ends of the patient care advised with a note of: "Carrier requires precertification. However every time we attempt to obtain precertification we are given the misdirection and runaround." Advise someone in your provider's management staff that this is ongoing and to have the provider service rep notified.

2) When it comes time to contract renewal or discussion, if a log has been kept of name, date, time, and resolution this can be used to your advantage in negotiations.

Hope this helps

 

[MrLittlefoot]

Before sending appeals and writing to your state insurance commission find out what type of coverage the patient actually has. If they are an actual insurance company that stuff will work, but if they are a healthcare trust or a benefits administrator for an employer or union, there is a high likely hood that they aren't regulated by the state your office is in and a letter to the insurance commission is a waste of your time and they will ignore you or sent you a rejection letter. Instead these types of plans are regulated by the Department of Labor as employee benefits. If they are DOL regulated the DOL only give appeal rights to plan members and their authorized reps. If this is the case, find out the procedure to become an authorized rep if the patient will let you and tackle it that way. If that doesn't work, then you can file a complaint with the DOL. And if you've ever been audited by the DOL, trust me you know that will put them in a world of hurt.