Wiki Prior Authorization

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JAMETH345

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I'm guessing a lot of people run into this: Before performing a procedure, we check benefits and eligibility, the insurance says no prior authorization is required. When we bill for the procedure, they deny for no prior authorization. Usually we're not able to get the "No Auth Required" in writing. When we say Jane told us no prior auth required, and provide the reference number from the call, they say no one told you that. Or they send to reprocess, and it still gets denied. What can we do to avoid this? The denied claims are really adding up, and it eats up a lot of time with few good results. I would appreciate any helpful tips.
 
Check policies on the payer website. Get names, dates, and times if no reference number is available. I used to get the run around from benefits/eligibility. I didn't both with them, because in the end I'd need to check with PA department anyway.

I had one tell me no auth was needed, but then on their clinical policy it said big and bold "Authorization required with JXXXX." But they didn't want to give me an authorization until I pushed and we had received a denial.
 
What is the practice specialty?
Are you checking the specific medical policies of the payer and the separate pre auth such as through AIM for example?
Are you using portals such as Availity, Cigna provider portal, or the UHC provider portal, etc.? Calling really is not the way to go. Some practices, depending on size, have entire teams dedicated to only this process or they completely outsource it.
Are you sure the codes you are calling about are correct in relation to what is on the order or plan of treatment? Is something different actually being coded and billed on the claim which is then denied because it does not match the code(s) you called about or pre-authed?
Do you have an EMR with connectivity or the ability to do this function electronically?
There is a lot that goes into this and the practice needs a process other than just calling to "verify benefits and eligibility" when it comes to high cost procedures or surgeries.

Examples: https://www.uhcprovider.com/en/prior-auth-advance-notification.html
 
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