Author Topic: Insurance & Authorizations  (Read 3921 times)

Michelle1965

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Insurance & Authorizations
« on: October 26, 2014, 12:25:53 AM »
As we all know in Medical Billing it starts at the front end in regards to collecting patient demographics, insurance, getting authorizations etc...  My question is as a Billing Company doing the billing for the provider's office if the provider's front staff doesn't get the proper insurance from the patient upfront, and verify their benefits, and get the authorizations etc.... what do you do?   
I actually work in a provider's office right now in the billing department, and have come across so many errors where the staff doesn't get the correct information, and at this point the patient was already seen.  This creates a problem especially when its a HMO plan and you need prior authorizations/referrals. I have contacted the insurances before to try and get the auth after the fact, and they wouldn't retroactive the auth.  They have lost revenue, because of these mistakes! 
If I start my own Billing Company can I put in the contract that if their front end staff doesn't get all of the proper information from the patient at the time of the visit, then any lost revenue due to this wouldn't be my companies fault?  Especially for prior authorizations, because by the time I would get their charge entry slips/superbills it would be to late , because at that point the patient has already been seen!  There wouldn't be anything I could do, unless there was a way for me to get the info before the patient comes in for their appointment, then I could do the verifying, and getting the authorizations myself (of course that would have to be included in my fee as well).  Any advice in this area would be greatly appreciated!  :)

PMRNC

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Re: Insurance & Authorizations
« Reply #1 on: October 26, 2014, 11:57:22 AM »
I have my clients use a pre-screening form, this gathers all the information we need at the time the patient makes the appt. I do authorizations because it just makes sense that whomever does verification of benefits can get the intial auth right there on the spot in most cases.
By time patient comes in for their visit the pre-auth and benefit verification and eligibility check has been done. If an auth needs clinical info I send back a form to the staff and the claim is marked incomplete. Once a week I give each client a report of incomplete claims.
Linda Walker
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kristin

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Re: Insurance & Authorizations
« Reply #2 on: October 26, 2014, 07:05:48 PM »
This by far the most frustrating issue I run across when doing billing for other offices. At my office, I do everything involving the billing, so I have no one but myself to blame if a mistake happens. And they rarely do, because I am very, very careful.

But for the remote work I do, it is a constant battle getting proper demos, auths, etc. I am at the mercy of various staff from offices, hospitals, and nursing homes who either don't do things correctly, don't know how to, or don't care to. I have made various forms like the one Linda mentioned for staff to fill out, I have spoken to the doctors and their staff, I have called the hospitals and nursing homes, and still find lots of errors.

So you can either be proactive, or reactive when it comes to this. Proactively give them forms ahead of time, and/or do the demo entry and auths and verifications yourself. Or be reactive, and when claims deny because you were given bad info, correct them on the back end. Proactive is the way to go, but it is easier said then done, as I have discovered over the years...so I find myself being reactive more than I would like to be, unfortunately.

Michelle1965

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Re: Insurance & Authorizations
« Reply #3 on: October 27, 2014, 09:03:38 AM »
Thank you so much Ladies for your view on this subject. I like the pre-screening idea, but I agree it probably is easier said then done! In this case of when you have to be reactive do you include this in the pricing of your fee, because in my personal opinion when your having to correct so many mistakes of other staff members it keeps you from doing a lot of the important things like follow-up etc... 
I'm just an employee right now for a provider, and have mentioned this to the practice administrator several times, and she says to me its not going to change, because we have talked to the staff before about this.
I think if the provider had to pay a fee for errors made from their front staff not doing their job correctly, then they would definitely find a solution to the problem.  I totally agree this is the frustrating part as a Biller, and right now I can't change anything where I work, because they aren't listening to my advice, so I spend about 3 hours a day making corrections from other staff members  >:(, and they wonder why the A/R looks the way it does!  ::)

PMRNC

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Re: Insurance & Authorizations
« Reply #4 on: October 27, 2014, 01:01:14 PM »
Quote
I think if the provider had to pay a fee for errors made from their front staff not doing their job correctly, then they would definitely find a solution to the problem.  I totally agree this is the frustrating part as a Biller, and right now I can't change anything where I work, because they aren't listening to my advice, so I spend about 3 hours a day making corrections from other staff members  >:(, and they wonder why the A/R looks the way it does!  ::)

You could ask for a raise  :P ??? ;D  Go the extra mile and so some reports to show how much they are losing. Save them money and ask for a raise. I would :)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Medical Billing Forum

Re: Insurance & Authorizations
« Reply #4 on: October 27, 2014, 01:01:14 PM »

Merry

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Re: Insurance & Authorizations
« Reply #5 on: October 27, 2014, 10:14:38 PM »
In the "old days" about 25 yrs ago, I would charge the provider if I had to return a claim for insufficient info.  I charged 25 cents.  First bill was $147. All claims submitted after that were always complete.

kristin

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Re: Insurance & Authorizations
« Reply #6 on: October 27, 2014, 10:43:18 PM »
For my part, because I don't have a billing company, and am paid hourly for what I do as a subcontractor/employee, I get paid to fix all the mistakes I find, regardless. But if I DID have a billing company, I would absolutely factor this into my fee. Which is why percentage billing is not the way to go, because you won't recoup the effort you put in, when it comes to stuff like this.

I agree with Linda...while you are still an employee at your current job, show them how their staff is costing them money, and how you can increase their revenue. And get a raise for your efforts!

jennifer8055

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Re: Insurance & Authorizations
« Reply #7 on: October 28, 2014, 12:42:45 PM »
I had this issue when I started working at my current job.  The providers office had never verified patients insurance prior to their first appointment.  If they had not been in for awhile, they didn't verify to see if that insurance was still active.  I showed them how much we were having to "eat" because having to write off charges for services that had no authorization or referral because the patient didn't give us correct information.  You bill a claim - usual 7-14 day turnaround time for electronic claims to process...get a denial for "no authorization" - but now you can't get the auth because you only have 72 hours to get a retro-auth......you have to write off. 

Every where I had worked previously, we called the patients insurance and verified all benefits and even specific CPT/HCPCS codes that we may do, we do that here now.  For new patients, we get their insurance information when their appointment is scheduled and we have two girls that do nothing but insurance verification.  We have a standardized form that they use for every patient with in office procedure codes that could and DME codes that we could issue and we find out on the front end if those are covered, what the benefit is and if any precert/authorization is required.  Being a specialist office - it's imperative that we have these benefits verified because sometime a patient may have to be admitted and need surgery or need an MRI - you're able to schedule that sooner and take care of the patient because you already know if the patient needs a precert.

This has also been a HUGE help with collections.  We have an idea of what the patient may owe for deductible/coinsurance and if we need to do precert on anything.  This has made our denials/claim rejections go WAY down.  Our patient collections are up also because we are able to collect a better portion up front.  We are turning fewer patients to collections due to non payment of balances.  If you keep a track of how many claims are being unpaid/written off due to incorrect information, no precert/authorization done, etc - the manager and providers may change their mind quickly if they see how it affects the bottom line.

 

Medical Billing Forum

Re: Insurance & Authorizations
« Reply #7 on: October 28, 2014, 12:42:45 PM »