Medical Billing Forum

Billing => Billing => Topic started by: sls on August 10, 2017, 02:05:09 PM

Title: outpatient billing
Post by: sls on August 10, 2017, 02:05:09 PM
i have some procedures that normally would require pre authorization and we are billing as outpatient.  The patients in most cases are being treated observation/er and the hospital is ordering test..ex: 93306-93350. claims are being denied no authroization. We are billing with a 26 modifier. Do we have any recourse to get these paid since it should be the hospital who gets the authorization?   any help or advise is greatly appreciated
Title: Re: outpatient billing
Post by: Ruthie1972 on August 11, 2017, 07:02:57 AM
Some Insurance companies will not pay if the patient is listed under can also call the hospital and see if they can give you an auth# that you can put on the claim.
Title: Re: outpatient billing
Post by: sls on August 11, 2017, 12:41:11 PM
i did reach out to the facility and they stated they dont get prior auths for emergency rooms. Some plans do waive the prior auth on an emergency room basis.
Title: Re: outpatient billing
Post by: Michele on August 12, 2017, 09:18:35 PM
You mentioned that these were observation patients.  We have had issues with observation claims due to the POS.  If we bill with the wrong POS they deny for no auth.  Just wanted to mention that.
Title: Re: outpatient billing
Post by: PMRNC on August 13, 2017, 02:52:56 PM
This happens to my ped's quite often and MOST of our patient's policies state the patient is responsible for obtaining non-emergency authorizations. Now most hospital's DO indeed do them when possible. If the plan is an ERISA policy and either patient or hospital TRIED to obtain prior auth it can be appealed using ERISA guidelines but patient must be involved. EVEN in cases where patient did not obtain auth or the hospital did not an appeal can still be done but you may need both the hospital's cooperation and the patient's cooperation (If ERISA). Just to give you an example, MY personal plan under my husband's union requires us to pre-authorize any ER visits, but says that it can be the patient, patient's representative or the facility/hosp as long as it's done with 48 hours. Well our union hall (we are self-funded) is only open from 8 am to 4pm M-F and they do not even have an answering machine! We cannot call the plan administrator as they will refer us to our union hall. ANY and all denials I have received for no prior auth have been won VERY simply by appealing so long as I documented that either my provider or myself or anyone for that fact called them and when we attempted to call. They don't dare deny the appeal as we will go to the Dept of Labor as they oversee ERISA plans.

Bottom line, obtain a copy of the patient's plan and see what it says in regards to when pre-auth is required, how much time they have to pre-auth and WHO is responsibility for the pre-auth. You also want to find out the the availability of the pre-auth line first. If it is an ERISA plan, make sure the patient is involved and understands that they must either do the appeal or sign an authorized representative form.

If you are billing the professional component, your office could also be responsible for the pre-auth. For my clients, I will call the plan to make sure their is a pre-auth and if not see if they will give me one.