Billing > Billing

pre authorizations

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sls:
have patients that are in observation. tests are ordered, that normally require pre authorization.  we perform the test, patient is discharged.  getting denials no pre authorization.  is their a guideline to follow for these tests, the doctor is called in, we have no prior knowledge these tests are being requested. hospital does not get auth's for outpatient procedures.  any ideas...????

Michele:
Who is requesting the tests?  Isn't the doctor requesting the tests?  I'm not sure what services are being denied, the doctor or the tests?

sls:
physicians are doing fee for service services such as 93010-93305-93458.  Being denied for the physician portion as no authorization.  we dont have one because the patient was treated as outpt observation. never admitted.  I am hoping there is some way we can get these paid.  IBC is denying all of our visits.

PMRNC:
If the procedures require pre-auth than there has to be a process for the office or the hosp to provide the pre-auth services. I would ask the patient for a copy of their summary plan benefits, it might be that they are responsible for pre-auth and if they did not request a pre-auth they would be responsible for the charges. I'd also pull a copy of the contract as well just to be on safe side.

Michele:
We do quite a bit of hospital observation billing.  If we bill for services that do not match up with the hospital our services are often denied for no auth.  The services actually didn't require auth but because of what we billed vs what the hospital billed that is the denial we receive.  Is the provider determining what tests are to be run?  Or are the tests being ordered by someone else?  First determine if the denial is actually accurate.  Call the insurance carrier and talk to a representative.  Many times during this conversation the issue will be discovered.  If an auth is truly needed then the provider will have to make sure that is being done either by his/her staff or the hospital. 

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