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Wiki No pre-auth, provider responsibility?

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brenda@geminibilling.com

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Hello,

If pre auth is required and the office fails to obtain one is this the provider's responsibility? Are we allowed to charge the patient for anything, legally?

Thanks in advance!
 
You could bill the patient; however, if you are an enrolled healthcare provider with the payor, you must follow the contractual terms of the agreement in addition to the guidelines set forth in the provider manual. Following adjudication, if denied for no authorization, you might be obligated to write off the billed amount and not bill the patient. If the practice develops a pattern of this, the provider could find him/herself being removed as an enrolled provider.
 
Your contract may allow for post-claim medical necessity review if precert is not obtained before the service. I'd check that out before writing off the service. Honestly, I'd appeal on medical necessity regardless of the contract!
 
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