Wiki Retro-authorized claims can be paid at 50% per CA state law?

[shannonbohner]

I just got off the phone with local BCBS in CA, and was told that the retro-authorized visits we had approved would be paid at only 50% of the allowed amount "per California state law" as the visits were authorized after the treatment was rendered. I have never heard of this and cannot seem to find this law anywhere online. Is this true?? The BCBS rep said at first that it was not to be paid at all per this law, so as she went back on her word I am questioning this completely. She also wouldn't let me speak with her supervisor.

 

[sls314]

I just got off the phone with local BCBS in CA, and was told that the retro-authorized visits we had approved would be paid at only 50% of the allowed amount "per California state law" as the visits were authorized after the treatment was rendered. I have never heard of this and cannot seem to find this law anywhere online. Is this true?? The BCBS rep said at first that it was not to be paid at all per this law, so as she went back on her word I am questioning this completely. She also wouldn't let me speak with her supervisor.

If I were you, I'd find out whether the patient was on an ERISA plan, what your BCBS contract states, and whether any state law exists about retro authorizations. You'd need to know that information to know how you could proceed and what avenues (if any) you might have to obtain full payment.

I'm not sure about California state law, as I am not located in California.

However, I've seen many managed care contracts that apply a financial penalty for retro authorizations. I'd look in your BCBS contract to see if it contains a similar provision.

(50% of the allowed amount for failure to obtain a timely authorization would not be THAT unusual in a contract. Some companies don't allow retro authorizations at all, and if you're a contracted provider you could potentially receive no payment and end up having to write off the entire claim. (Depending on your contract, whether the patient's plan requires authorization, whether its an ERISA plan, and so forth.))

 

[awnw211@yahoo.com]

How far back is the retro date? Medi-Cal (CA Medicaid) reduces reimbursement depending on the timely filing of the claim. DOS within 180 days are paid at 100%, 7-9 months are 75%, 10-12 months are 50%, and anything after 12 months is past the limit at for 0%. Hope this helps.