Wiki Obtaining precert/authorization

[maine4me]

I am interested to find out how other offices handle this situation. A patient is admitted to the hospital by another physician group. Our doctor is called in as a consulting physician (Infectious Disease is the specialty), we bill our claims and are denied for no authorization. The patient has Medicare but Part A only, so we had to bill the Blue Shield plan on file. Now typically we would rely on the hospital to obtain the auth, but in this case they only followed the Medicare requirements because to them Medicare is primary. Now I have a denial and am not sure how to proceed.

Any ideas?

 

[jackjones62]

I would contact the physician's office that admitted them, they would have had to get authorization in order to get paid as well; if that does not work, appeal based on the argument that your physician was called in as a consult and you should be covered under the umbrella of the admission; also, with regards to insurance coverage, if the pt. has BCBS and Medicare Part A; most likely, BCBS is still primary, but you need to check benefits as well; you have a valid argument here and need to be agressive with the insurance company; exhaust all BCBS appeal options, if that fails, request external review.

Jennifer
CT ENT