What Happens If Your Prior Authorization Doesn’t Match With Service Provided?

Prior Authorization for a drug is one of the foremost processes on which the financial health of a Pharmacy facility depends on. Today, with the advancement in the areas of EMR and EHR, Pharmacy billing personnel who work in-house or offshore have to guarantee in advance to their doctors about the patients insurance plan. While some claims are processed smoothly right as the patient is treated most of them get denied or delayed as the prior authorization query does not match the service provider’s data base.

In most cases, the best way to avoid compliance issue with prior authorization is by obtaining an authorization that precisely reflects what will be provided. For those procedures where the doctors thinks more services may be needed or more units may be required, the authorization should include all potential treatments or should include the maximum number of units that may be used.

Also, do remember that if you and your facility are constantly being rattled by the denied claim calls, don’t be disheartened, you are not alone.

So the moot question that stands here is, how he / she can manage the incoming barrage of denied and delayed claims, pertaining to prior authorization.

  • For those claims in which the prior authorization does not match the services provided, experts recommend a procedure that wants the provider to communicate with the facility as soon as possible to the appropriate staff for change in prior authorization. Do remember that it might not be necessary for instances where the units or the service level are below the prior authorized numbers. Billing of the procedure should be done until a changed prior authorization is obtained.
  • In the recent three to four years there have been many practices where the solution to an incorrect prior authorization is to report the services that were authorized even when the Pharmacy record indicates other services were provided. But, for some claims, this may be the only way to get reimbursed. In such a scenario, expert’s suggestion would be to use all avenues of appeal. This means change in authorization to clearly notify the payer of what services were actually provided and the documented reasons for the service, accepting what you can in the end, and avoiding this in the future with the changes recommended above.

What Happens If Eligibility Verification And Pre-Authorization Are Not Conducted By Your Pharmacy Billing Department?

With the Affordable Care Act, insurance and eligibility verification is absolutely critical. Identifying patient responsibility upfront prior to the visit is critical to managing the receivables. When not conducted, the absence of proper eligibility and benefit verification, countless downstream problems are created; delayed payments, reworks, decreased patient satisfaction, increased errors, and nonpayment.

Prior Authorization Features You Should Know:

  • Receive Schedules From The Hospital Via EDI, Email Or Fax
  • Verify Coverage On All Primary And Secondary (If Applicable) Payers By Utilizing Database, Payer Web Sites, Interactive Voice Response Systems, And Phone Calls To Payers
  • Contact Patients To Get Updated Insurance Information
  • Provide The Clients With The Results, Which Include Eligibility And Benefits Information Such As Member ID, Group ID, Coverage End And Start Dates, Co-Pay Information, And Much More

Additional Procedures and Services Related To Prior Authorization:

  • Obtain Pre-Authorization Number
  • Obtain Referral From PCP
  • Enter/Update Patient Demographics
  • Remind Patient Of POS Collection Requirements
  • Inform Client If There Is An Issue With Coverage Or Authorization
  • Process Medicaid Enrollment