Author Topic: referrals, authorizations, care notifications?  (Read 1737 times)

Anne

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referrals, authorizations, care notifications?
« on: July 07, 2009, 04:56:44 PM »
I know what these words mean, however, can someone tell me how I know when an auth or notification is required.  When I've called or looked up patients eligibilty and benefits, I'm told they do not need pre-certification. Primary Insurance consistantly pays on claims for over 3 years!! Then, out of the blue I got a denial saying I should have gotten an authorizaton number.  I called said we didn't have to get that on other claims, and then told that ALL the other claims were paid in error!  Also, was told that ALL patients being treated in the home of the patient have to have a Care Notification/authorization.   Is "place of service" something not looked at very closely in processing?  I wonder if I should be requesting Care notification numbers for ALL patients.  Patients I bill for are all treated in the home for PT, and OT.  How could it possibly be that ALL claims were paid "in error"?  I'm talking about thousands of claims.

PMRNC

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Re: referrals, authorizations, care notifications?
« Reply #1 on: July 07, 2009, 05:49:23 PM »
If you are doing PT and OT then chances are you always need an authorization with most plans, as for claims being paid in error, yes it happens a lot. 
Linda Walker
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Pay_My_Claims

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Re: referrals, authorizations, care notifications?
« Reply #2 on: July 07, 2009, 06:00:08 PM »
I know what these words mean, however, can someone tell me how I know when an auth or notification is required.  When I've called or looked up patients eligibilty and benefits, I'm told they do not need pre-certification. Primary Insurance consistantly pays on claims for over 3 years!! Then, out of the blue I got a denial saying I should have gotten an authorizaton number.  I called said we didn't have to get that on other claims, and then told that ALL the other claims were paid in error!  Also, was told that ALL patients being treated in the home of the patient have to have a Care Notification/authorization.   Is "place of service" something not looked at very closely in processing?  I wonder if I should be requesting Care notification numbers for ALL patients.  Patients I bill for are all treated in the home for PT, and OT.  How could it possibly be that ALL claims were paid "in error"?  I'm talking about thousands of claims.

UHC uses "care notification" a lot. Authorization is approval for services. Prior approval for services not rendered. Care notification is not an "authorization" but just notifying them that services are being done. This is done by an intake coordinator and not per sey a nurse who will request clinical information. They will ask for a dx and other demographic information and state "care notification" has been met. The Medicare PFFS does that a lot as well. Are you dealing with a particular payor, or various ones??? It all comes down to the verification process. If you work a specialty, they will give you benefits, but you have to ask the specific questions. If you don't ask, they won't tell. If you ask if prior approval is required, they will say no. Some will say no but notification is required.

And as Linda stated, they do pay in error a lot. That is why they do audits, and unfortunately recoup

PMRNC

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Re: referrals, authorizations, care notifications?
« Reply #3 on: July 07, 2009, 07:35:51 PM »
Quote
And as Linda stated, they do pay in error a lot. That is why they do audits, and unfortunately recoup

On something like that they would have a hard time recouping, if they paid a NON covered or excluded service that's one thing.. but they would lose legally if they went after charges they paid for not having prior authorization as it's what's called a "set claim precedence" meaning they set the precedence for future claims.  I had a client one time challenge a TPA for BCBS because they paid claims for over a year without authorization and then later said.. Oops we were wrong.. not only did he win and not have to pay them back, the TPA had to consider all charges for a certain amount of time w/out authorization. I came into the picture after the judgment was awarded, he did it on his own.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

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Re: referrals, authorizations, care notifications?
« Reply #4 on: July 07, 2009, 08:08:40 PM »
hummmm, I have seen them take the monies back, but not on a 3 year time frame. It was paid, then recouped. I will keep that in mind if I have a client in that situation.