insurance saying - No Authorization Required - then deny

[TIVAndy]

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anyone have issue with this at their practice
- submit prior auth for a case (intracept, SCS, whatever it is) and you proceed with it , then they come back and say they won't pay?

how do you guys deal with this? i am now always skeptical of NAR status for procedures, but i'm not sure how to approach this.
take deposit from pts?

 

[Ferrismonk]

Yes. Only way I know is to appeal nonpayment, but usually you just have to eat it in the end if it's a smaller procedure. Ridiculous.

 

[Painologist]

anyone have issue with this at their practice
- submit prior auth for a case (intracept, SCS, whatever it is) and you proceed with it , then they come back and say they won't pay?

how do you guys deal with this? i am now always skeptical of NAR status for procedures, but i'm not sure how to approach this.
take deposit from pts?

100%. No auth required is the worst. I don’t mind getting auth if it guarantees payment.

 

[Status Sciaticus]

can you do a precert or predetermination to avoid this issue?

 

[Welcome123]

can you do a precert or predetermination to avoid this issue?

Predetermination is probably the safest bet but expect that administrative errors (your staff and insurance staff) as well as time may make some procedures just not worth doing. I would do it for any big ticket procedure

 

[Dr. Ice]

“Authorization not being a guarantee of payment” is what ultimately led me to leave my last job as my AR from last year was over a milllion. The entire practice was like 22 million in AR because we did not follow ever any LCD or whatever private insurance version of it. Back denials, non payment after auth were like subcategories of this

 

[Painologist]

“Authorization not being a guarantee of payment” is what ultimately led me to leave my last job as my AR from last year was over a milllion. The entire practice was like 22 million in AR because we did not follow ever any LCD or whatever private insurance version of it. Back denials, non payment after auth were like subcategories of this

This is plaguing my practice. So hard to satisfy every detail for even single no auth required procedure. Charity procedures.

 

[Taus]

This is plaguing my practice. So hard to satisfy every detail for even single no auth required procedure. Charity procedures.

it’s not easy and requires several hours of work upfront, but it’s doable. Split the work with your partners. Go through each lcd (plus carelon, evicore, etc) and make templates. Load into your emr and insert into notes whenever you order a procedure.

 

[Agast]

The explanation is, there is “no authorization required” for a procedure that is not in their formulary. Because one cannot authorize a non-formulary procedure. That is a hint you need to get a predetermination. It sucks because it tends to be an expensive mistake.

 

[TIVAndy]

The explanation is, there is “no authorization required” for a procedure that is not in their formulary. Because one cannot authorize a non-formulary procedure. That is a hint you need to get a predetermination. It sucks because it tends to be an expensive mistake.

Can you guys expand on how to get predetermination? We had a stim case that was NAR and had to eat the cost for the asc. Big loss

 

[Kissmyabjj]

This happened to me recently. No authorization required for either of the diagnostic lumbar medial branch blocks. However, when I then requested RFA after both blocks were incredibly successful, the procedure was denied.

 

[powermd]

FBC doesn't require auth, but I've had no problems with them paying. They request notes be MAILED to them for every RF. There is a fax number, although it's not on the letter requesting the records, so I'm left to wonder if a fax is adequate. I've been doing both.

United in Maine doesn't seem to require PAs at least for office based. I haven't had problems with this yet.

The commercial policies through ERISA are variable. Some employers opt in or out of PA, and not for every service. The only way to know is to call and wait 45-60 min on hold to find out. We charge a PA admin fee for this, even if it doesn't ultimately require a PA.

With some of these the only way to know is to run a test bill and see. I'm not sure if the VA pays for genicular RF, and when you call they refer you to the VA fee schedule- which is totally incomprehensible. The numbers make no sense. So I did a test case- the paid the blocks on one guy. Now we'll do the RF and see. Next patient won't get done unless that one gets paid.

 

[Agast]

This happened to me recently. No authorization required for either of the diagnostic lumbar medial branch blocks. However, when I then requested RFA after both blocks were incredibly successful, the procedure was denied.

Was it denied because they were no physical therapy notes? I’ve noticed some Blue Cross Blue Shield policies in states like Illinois require evidence of conservative treatment before RFA even if they paid for the MBBs already

 

[powermd]

Was it denied because they were no physical therapy notes? I’ve noticed some Blue Cross Blue Shield policies in states like Illinois require evidence of conservative treatment before RFA even if they paid for the MBBs already

I don't even try without PT. The feedback we just got on a recent BCBS case was 4 weeks minimum.

 

[Status Sciaticus]

Can you guys expand on how to get predetermination? We had a stim case that was NAR and had to eat the cost for the asc. Big loss

What is NAR?

FBC doesn't require auth, but I've had no problems with them paying. They request notes be MAILED to them for every RF. There is a fax number, although it's not on the letter requesting the records, so I'm left to wonder if a fax is adequate. I've been doing both.

United in Maine doesn't seem to require PAs at least for office based. I haven't had problems with this yet.

The commercial policies through ERISA are variable. Some employers opt in or out of PA, and not for every service. The only way to know is to call and wait 45-60 min on hold to find out. We charge a PA admin fee for this, even if it doesn't ultimately require a PA.

With some of these the only way to know is to run a test bill and see. I'm not sure if the VA pays for genicular RF, and when you call they refer you to the VA fee schedule- which is totally incomprehensible. The numbers make no sense. So I did a test case- the paid the blocks on one guy. Now we'll do the RF and see. Next patient won't get done unless that one gets paid.

What is FBC?
Mailed notes is wild AF

 

[BobBarker]

NAR: no auth required.

It is good code when you are talking to your scheduler. I use it all of the time when the patient can hear. We have two docs so I can’t always do an add on.

“Hey Patty. This is Mr Jones. Book him with me first available for the procedure I just ordered. It is NAR.”

This is understood code in my office that this is just a quick procedure but the other doctor is a little behind with scheduled procedures or I have to go to soccer. She understands she can just double book an early AM office visit anytime and I will knock out the epidural/mbb. I do this sometimes for Medicare advantage or UHC that don’t want to pay mod -25.

 

[powermd]

What is NAR?

What is FBC?
Mailed notes is wild AF

Federal Blue Cross

 

[BobBarker]

Whoah, I’m unaware of any problems we are having with bcbs fed. I have a ton of patients with that.

 

[powermd]

Whoah, I’m unaware of any problems we are having with bcbs fed. I have a ton of patients with that.

Your staff probably just sends the notes on request. I haven't had any issues getting paid, but they always ask on RF cases. Later I get a letter saying it was authorized. They definitely pay better than the state BCBS does.

 

[Bostonspine]

I don't even try without PT. The feedback we just got on a recent BCBS case was 4 weeks minimum.

This is the game Blue Cross/Shield play in our state they ask for all the evidence after it’s done… I require a visit to document everything even if auth is not required… one of my partners would just do procedures when no auth is required and his collections were terrible as a result

 

[DoYouEvenLiftBro]

it’s not easy and requires several hours of work upfront, but it’s doable. Split the work with your partners. Go through each lcd (plus carelon, evicore, etc) and make templates. Load into your emr and insert into notes whenever you order a procedure.

We have templates for every insurance with whatever icd10 and cpt we’re doing, it’s saved us a lot of headaches/hassle

The MAs are trained to put those in

Secondly, the billers before billing if they find something off will just teams us with a suggestion to fix
Our template takes care of this usually but an easy example would be:
“You’re requesting SIJ and have only 2 exam maneuvers”
“There is 10% leg pain this insurance will deny the mbb with any leg pain”

 

[gaschicago]

how did you training billing to catch these things? do you mind sharing the templates for medical necessity you are using?

 

[clubdeac]

Insurance companies are pure evil

 

[kstarm]

We have templates for every insurance with whatever icd10 and cpt we’re doing, it’s saved us a lot of headaches/hassle

The MAs are trained to put those in

Secondly, the billers before billing if they find something off will just teams us with a suggestion to fix
Our template takes care of this usually but an easy example would be:
“You’re requesting SIJ and have only 2 exam maneuvers”
“There is 10% leg pain this insurance will deny the mbb with any leg pain”

I hear this, It has turned into this weird game of trying to get the right information into the note to satisfy insurance criteria vs being completely accurate with what is going on with the patient. How many times is MBB the right next step and the patient also has leg pain? Its like a person can't have two pain generators. I also dont like how my notes are starting to sound the same because if I say something off script my staff and I have exponentially more work to do to get through a denial. The work continues to shift to game theory (how do I get this approved) vs how I would actually describe and discuss what is going on with a patient.

 

[clubdeac]

I am now having to do P2P to get approval for the location of a procedure. I’m hospital based so now they deny bc it’s done at a hospital. It’s getting effing unreal

 

[JFS]

I am now having to do P2P to get approval for the location of a procedure. I’m hospital based so now they deny bc it’s done at a hospital. It’s getting effing unreal

I’m hospital based and have HOPD and in office suite.

If you are close to whoever is submitting you should make sure they know the boxes to check. My auth team flagged me for a question that asked where the procedure would be done, and included an option to say that you didn’t have access to ASC. I’d imagine this particular insurance would have denied if I said I’d do it in HOPD but didn’t check to say I didn’t have access to ASC.

If you do have office suite sometimes have to check inc procedural risk factors, procedural anxiety etc etc for HOPD.

 

[SSdoc33]

I hear this, It has turned into this weird game of trying to get the right information into the note to satisfy insurance criteria vs being completely accurate with what is going on with the patient. How many times is MBB the right next step and the patient also has leg pain? Its like a person can't have two pain generators. I also dont like how my notes are starting to sound the same because if I say something off script my staff and I have exponentially more work to do to get through a denial. The work continues to shift to game theory (how do I get this approved) vs how I would actually describe and discuss what is going on with a patient.

This is true.

My notes are worse and I purposely exclude relevant information bc it is best for the patient, but an incomplete picture of the actual problems.

Insurance is creating worse care with their requirements.

 

[powermd]

This is true.

My notes are worse and I purposely exclude relevant information bc it is best for the patient, but an incomplete picture of the actual problems.

Insurance is creating worse care with their requirements.

I've often wished my EHR had a split visit note- the real A&P and the bizaro-world insurance version.

 

[Ducttape]

I am now having to do P2P to get approval for the location of a procedure. I’m hospital based so now they deny bc it’s done at a hospital. It’s getting effing unreal

you should send a message of thanks to those who are trying to eliminate HOPD as a site of service.