What happens if a session requires pre-authorization but the client does not have one?

Prior authorization or pre-authorization is the process of getting approval from the insurance to determine coverage of services, beforehand. Factors important to get approval include medical appropriateness, medical necessity, and benefit limits. The payer assigns an authorization number during pre-authorization. The number must be included in the final claim submission.

Obtaining pre-authorization in the majority of the cases is considered the sole responsibility of the provider. Patients are least aware of the processes at the back end and do not have a good understanding of insurance requirements. A provider must be thorough with all the policies and requirements mandated by insurance.

If a session requires pre-authorization, and the client did not obtain it, either the client is left with an unpaid claim or the provider absorbs the cost of the treatment, depending on the policy. If the client was aware of the necessary pre-authorizations required and still did not obtain them, the client is liable to pay the bills. But, if it is the provider’s carelessness, then the providers bear the costs.

There are still chances of overturning a denial due to pre-authorization by appealing again. But if the pre-authorization process was not followed in the first place, the insurance is not obligated to reimburse the payment. However, some payers accept retroactive authorizations, that is obtaining authorization after completion of the procedure.

pre-authorization not authorized

While appealing again, keep the followings things in mind:

• Check if pre-authorization is necessary for every visit and procedure.
• Verify the Current Procedure Terminology (CPT) codes for prior authorization. Invalid CPT codes could lead to denial. It is better to pre-authorize all the procedures to be on the safer side. If any procedure is not completed, there is no penalty for that. Be sure to comply with the payer’s guidelines.
• Let the evidence-based clinical guidelines issued by the government and standard organizations lead and your appeal. It is one of the best ways to support your claim appeal and obtain pre-authorization.
• Be sure to mention any medical history which justifies the medical necessity of the procedure. Keep your claim well documented to avoid any denials.

As a provider, you must double-check pre-authorization requirements before-hand. This could save a lot of time afterward. Pre-authorizing the procedures helps in faster claim processing. But in case, the client did not obtain pre-authorization, do not hesitate to appeal again. It might take up some time and resources but proves to be fruitful. A little more effort and help from professional medical billing services firms can help overturn a payer’s decision. You may be able to convince the payer to backdate the authorization.

Expert service companies that entirely focus on the authorization process are aware of the minutest details. When you choose to engage professionals you can focus more on the core activities of your practice, while the experts ensure all authorizations are in place.

Atlantic RCM is one of the leading multi-specialty medical billing companies in USA that serves 25+ major medical billing specialties. Our experts work across your practice in billing, collections and account receivables management, to help you succeed.

Get in touch with the leading medical billing outsourcing company to learn more. Call us at (469) 501-1500 or write to us Info@atlanticrcm.com