Wiki NO AUTH DENIALS AFTER ED ADMISSION

[orthobiller2017]

Hi

I have providers that work for a partner hospital with an Emergency Dept. They often do trauma surgeries on cases referred to them from the ED but POS is 21. We get denied all the time for no authorization. Sometimes we have auth from the partner hospital but most times not and also sometimes the carrier will not honor the hospital auth since we are billing for the MD.. A lot of these cases are captured Medicaid plans. We tried modifier ET but that didnt work. We appeal with the documentation showing these are ED directed patients but most times no luck.
Any recommendations?

 

[thomas7331]

If this is a recurring problem with specific plans, my recommendation would be to escalate this by trying to get a provider network representative from those plans to work with you to find a resolution. I recognize that for some plans, this might be easier said than done, but if you're not able to get these situations resolved through normal channels, then you really don't have a choice but to escalate it to someone with more authority.

If the plans do not respond and/or cooperate, then you may want to get an attorney involved, or contact your state's insurance commissioner if the particular plans fall under their jurisdiction. And if you're dealing with Medicaid plans, then you also have to option of going to your state legislators as well, who can put pressure on the government agencies that oversee the administration of Medicaid in your state. I've had success going this route once in a situation where I simply couldn't get the Medicaid to respond to my concerns.

Hope these suggestions may help some.