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Surgical prior auth

  1. Default Surgical prior auth
    Medical Coding Books
    I am needing help with a surgery getting denied by their insurance. Patient was admitted thru the er. The hospital staff prior authorized the inpatient stay but did not get one for any surgeries, with the insurance company with a diagnosis of back pain. The patient went on to have spine surgery during this stay. The insurance has paid the hospital including the operative charges, even our assistant surgery charges ( assistant surgeon does not need a p.a.) but they have denied our primary surgeon charges. Any suggestions to get this corrected? By the time it gets to our office to bill it out the patient is usually already home & recovering from surgery?

  2. #2
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    Columbia, MO
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    12,960
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    prior authorization of a procedure is the responsibility of the performing provider or the providers staff not the hospital. if your provider is being called in to perform surgery on an emergency basis, most if not every payer allows 24 hours to retro obtain the authorization. you should know within 24 hours if your physician performed a surgery on a patient and obtain the authorization, if it was not an emergency procedure then you definitely should have been informed prior to the physician performing the service as to what was being planned. Maybe I am missing a piece of this puzzle but everything points to a breakdown in communication and your office is not going be paid.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default Prior auth
    So, the patient comes to the hospital ER on a Friday night, has surgery on Saturday, then the billing office is back in on Monday and finds out about it. That is more than 24 hours. It has always been my understanding that the hospital needs to get the P.A. Not sure how they got paid without one.

  4. #4
    Default
    Quote Originally Posted by Sandy H View Post
    So, the patient comes to the hospital ER on a Friday night, has surgery on Saturday, then the billing office is back in on Monday and finds out about it. That is more than 24 hours. It has always been my understanding that the hospital needs to get the P.A. Not sure how they got paid without one.
    In an emergency, many commercial policies won't strictly enforce the authorization requirements but the information on the surgical claim doesn't necessarily show that the situation was emergent, so it's still a good idea to follow up promptly even if it's more than 24 hours to make sure all of the information for payment is in place. Or if that's not possible or it's already too late, you may need to make contact with the payer or go through the appeal process to try to resolve this.

    Really this is something you should take up with the insurance company - there isn't a magic bullet for these situations because every payer and plan has different rules and policies and you need a strategy based on the specifics of the organization you're dealing with. I'm assuming your provider is contracted with the payer, so there should information in your contract that spells out the authorization and payment responsibilities of both the provider and the insurance company - make sure you're familiar with this so you can show you have met your obligations and can also hold the payer responsible if they have not met theirs. There should also be a network representative available to work with you on this and give you guidance to help resolve these types of issues. If they won't work with you to come to a satisfactory solution, you can leave the network (threatening to do this will often get their attention and action if all else fails). Or, if your provider is not contracted and you cannot get resolution with the payer, then you are within your rights to hold the patient responsible for the charges, and the patient will need to make their case to their insurance company if they think it should be paid.
    Last edited by thomas7331; 05-18-2018 at 07:48 AM.
    Thomas Field, CPC, CEMC

  5. #5
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    I agree there is no way for the provider's office to get authorization on an emergent weekend surgery. Our hospitals always obtain authorizations for those. I have on occasion still received a denial. Sometimes the specific procedure code was not put on the authorization or like in your case the authorization was only for the inpatient admit. Usually a phone call to the insurance explaining the situation resolves these. I have also had to write a strongly worded appeals and have had to get our provider rep involved when all else fails but this has never been a big problem and they do usually end up being paid. If you come in on Monday morning to find your doctor performed surgery Friday night and the hospital has an authorization on file, you would have no reason to obtain another authorization. That's basically what you have to fight.

  6. #6
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    This seems to be an ongoing issue for our office as well. Patient's will go thru the emergency room and then have surgery. This happens over the weekend and seems like especially around the holiday's. There is no one at the hospital to obtain an authorization on the weekends and by the time the patient's name shows up on the hospital report we pull up each day it is past 24-48 hours. Sometimes the patient's have never stepped foot in the practice before so they are new patient's. The claims are submitted without an authorization and get partially or fully denied depending upon procedures performed. We always file an appeal and submit hospital paperwork to reflect patient came thru emergency room and then our provider was consulted for surgery. There is one insurance in particular that still denies the claim for no authorization. Is there a better way to show the procedure was emergent and couldn't wait until normal office hours so the provider staff could obtain authorization?

    How do other offices handle this? Does your provider bring a list of all patient's seen over the weekend on Monday morning or if it's a holiday, the following work day? Like I said earlier, we have access to hospital records, but the patient name doesn't always show up by Monday, sometimes the names don't show up until later in the week so that's even longer than 48 hours.

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