Medical Billing Services

Are you Constantly Receiving Denial Code CO-197?

What is Pre Authorization?

Most of the carriers request to obtain prior authorization from them before the service/surgery.  Prior authorization for health care services is required for certain services. If authorization is not obtained prior to performing the service, the insurer may not reimburse for the procedure. Most services requiring prior authorizations are surgical procedures or high-cost ancillary services or may be determined as not necessary in some circumstances.

The requirement for prior authorizations can lead to delays in needed healthcare, affecting both patient outcomes and patient satisfaction. Depending on what the patient’s coverage documents and the provider’s contract with the insurer say, neglecting to obtain preauthorization can result in reduced reimbursements or lower benefits for the patient. Services that don’t require preauthorization can be subject to review in some cases.

How to take Pre Authorization?

The key to a solid preauthorization is to provide the correct CPT code. The challenge is that you have to determine the correct procedural code before the service has been provided (and documented) — an often difficult task. To determine the correct code, check with the physician to find out what she/he anticipates doing. Make sure you get all possible scenarios; otherwise, you run the risk that a procedure that was performed won’t be covered.

The method to obtain prior authorizations can differ from payer to payer but usually is performed by either a phone call, the submission of an authorization form, or an online request via the payer’s website. Most often, payer portals are the preferred method of submitting prior authorizations. The portals may allow you to register for access, or you may have to gain access through your facility’s administrator.

To determine whether a service requires an authorization, you must be aware of each payer’s policies, which can usually be found on the payer Website and the payer/provider contract. Because of the need to describe medical necessity, this is most commonly performed by a medical assistant or other staff who can effectively communicate with the payer with an understanding of medical procedures.

Missed to take Pre Authorization?

With some insurers, you can get authorization retroactively, but with others, retroactive authorizations aren’t given, even if failure to get it in the first place was a mistake. Still other insurers may overturn a denial based on lack of preauthorization if appealed, but generally, they’re not under an obligation to make the reimbursement if the process for preauthorization was not followed.

When services are provided without expected preauthorization, what happens next depends on the insurer and the specific policy under which the patient is covered. Some insurance plans state that if a patient seeks services requiring pre-authorization, but doesn’t obtain pre-authorization, the patient is liable for covering the payment. If a provider neglects to obtain pre-authorization and payment is denied by the insurer, it may come down to absorbing the cost of the treatment or trying to collect it directly from the patient, neither of which are good options.

In this case, the provider has to make a decision about whether to pursue collecting the payment from the patient. Some swallow the loss. Others send the unpaid bill to the patient, but doing so is bad business. Patients are both unaware of the process and not in any sort of position to guess what CPT code should be submitted to the insurance company.

We at Medical Billers and Coders (MBC) take the list of CPTs which will require Pre Authorization from insurance companies’ website. Pre Authorization makes sure timely payment from payer side. To know more about RCM services provide by us you can mail us at info@medicalbillersandcoders.com or visit us at www.medicalbillersandcoders.com.

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Medical Billers and Coders

Catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.

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