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Prior Authorization Administrative Fee - HELP!

mrsjehu

Networker
Messages
96
Location
Boise, Idaho
Best answers
0
Our office charges a small administration fee for prior authorizations. It is across all insurances, for medications and prior auths for specialists. We have one insurance stating that we can't do this. They say we are charging for a referral, their paperwork states that it is a prior authorization. I have an email into our Provider Rep w/ Medicare to make sure we aren't doing anything wrong. Please HELP! We are trying to get this fixed ASAP. If we are in the wrong we want to correct it.
 

Leenahz

Guru
Messages
125
Location
Roanoke, Virginia
Best answers
0
I've never heard of this practice. Do you balance bill the patient? I didn't think Medicare required referrals or pre-auths. Please let me know what the rep says.

Lena
 

mrsjehu

Networker
Messages
96
Location
Boise, Idaho
Best answers
0
Medicare does not require referrals or pre-auths. Some Medicare Advantage plans are starting this practice. Per CMS, you are not allowed to charge for any additional fees like pre-auths. However, they did state that is for part B medicare. That Medicare Advantage plans would have their own rules with this matter.
 

rsboyd09

Contributor
Messages
16
Best answers
0
The department I manage handles prior authorizations and I would have never thought of the patient having to pay for this service since it's the responsibility of the ordering physician to obtain the authorization. In doing a little research online it seems to be a common question especially for smaller practices and I can see where it can be time-consuming when you don't have enough staff to dedicate to this process. I will continue searching but so far haven't found anything directly through CMS saying it cannot be done, but you definitely want to know for sure. Here is a question I found online:

"Can you bill 99211 for the time spent by your staff obtaining a prior authorization of any kind for the patient?

A: The answer is no. An Evaluation and Management service must be given. This means, the patient?s history should be reviewed, a limited or some level of medical decision making should be made. If there is not a clinical need shown; then the 99211 should not billed."


I am thinking this would apply to any E/M code, as well as others. I saw another article where one practice was considering charging an annual "administrative fee" to its patients. You really have to weigh the pros and cons with this because patients already pay for health insurance, and to be charged additional non-covered fees could cause you to see a decrease in your patient population.

Please let us know what you hear back from your Medicare rep.

Rodney

Reference: https://www.rheumatology.org/Practice/Office/Coding/Coding_FAQs__Evaluation___Management/
 

Leenahz

Guru
Messages
125
Location
Roanoke, Virginia
Best answers
0
Advantage plans still have to follow certain CMS guidelines, however.

Personally, I think charging for pre-auths or referrals is excessive if it is found to be lawful. However, charging for outside paperwork like disability or FMLA is another story. I typically see $10 - $20 charged for these forms to be completed.

Lena
 

mrsjehu

Networker
Messages
96
Location
Boise, Idaho
Best answers
0
Some of the insurance companies are requiring significant amounts of information for the Prior Auths to specialists and testing. One insurance company wants to know what the CPT code(s), and dx will be of the physician/testing the patient is being referred to. So this requires a phone call to the specialists office/diagnostic which of course they don't know for sure what will be billed until they see the patient. These are not just referrals to see a specialist or specialized testing, it is a prior authorization similar to what is seen for medications.
 

xstichr159

Contributor
Messages
20
Location
Huntsville, AL
Best answers
0
The practice I work for tried this several years ago. They were quickly told by BCBS of Alabama that this was unacceptable and if they continued they would no longer be in network.
 
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