Wiki Medical Policy Compliance

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klamond

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We are having an ongoing issue in our office with denials for medical policies not being met prior to procedure performed. Just trying to get an idea of other practices workflow so we can for once and all nip this in the bud. Who is responsible in your offices to make sure this is reviewed prior to procedures? For years, we have asked our surgical booking team to review prior to booking but they refuse and say it should be the MD. Which yes, ultimately the MD should review but would need someone to be responsible to make sure they do. So they precert the case, state no auth needed and then claims deny based on medical policy. Any ideas would be appreciated. Thank you
 
I work for a commercial insurance company and in my experience most offices have ancillary staff who are responsible for identifying any medical policies that might be applicable to their practice and keep a list of the medical policies, which is reviewed and updated regularly. Then the provider can check the list to see if there is a medical policy that they need to review in relation to a proposed treatment or procedure.

For other practices a review of the insurance companies' medical policy library is part of the process of verifying benefits & PA requirements. If there is a medical policy for the recommended treatment at that point, then the information regarding the medical policy is given to the provider to review to determine if the criteria in the medical policy are or are not met.
 
This can depend a lot on the size of the practice or facility and what the specialty is.
As advised by Corinne above, there are staff that normally perform this function.
In large practices there are usually prior authorization teams who do this. They may work in collaboration with the provider's clinical team and coders, etc. to obtain auth and/or make sure the policy is met. Just because a procedure may not require pre-auth doesn't mean it will be covered or paid if the medical policy was not met.
The surgical booking team would not necessarily have the expertise or bandwidth to do this function.

An example from my experience is provider wants to schedule surgery, patient has gone through required non-surgical treatments (MRI, PT, etc.), nurse or MA of provider submits order, coders receive order and review against the medical record to check the codes, etc. Depending on the result of that it may be sent back to the clinic at that point. If everything looks good from a proposed plan standpoint the order moves on to the prior authorization team. The pre-auth team submits clinicals and requests auth as needed depending on the payer. Whatever the result of that is, it may go back to the clinic team at that point if there are issues. If not, it goes on the be scheduled.
 
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