Do YOU demand Pre-authorization? RESPONSES (part 2)

Do YOU demand Pre-authorization? RESPONSES (part 2)

Randall McFarland, CPO

RESPONSES (continued)
This subject comes up a lot in our offices. It is our company policy to not
perform any work till the payable is determined (Can't accomplish always).
Most of the time the insurance co. balk but will comply. I agree 100% that
the practice of paying what they want (ins. co.) instead of what is billed
needs to stop. Further shouldn't it be considered price fixing if all any
co. has to do is look up Medi Care fee schedules and discount by 30%.
CPO

Yeah, it is frustrating. I have a patient whom we had preauthorization from
Blue Cross before we started. We gave them the amount of services the
patient required and what it would cost. The patient is custom all the way
since he is presently of strong health (although a type II diabetic, and
weighs 400 pounds. IS 6 FOOT 5 INCHES, and wears a 14 1/2 shoe). Blue Cross
authorized the amount, and of course we extended the services authorized.
This was two months ago. Now I don't follow up every patients bill in regard
to the status of current payment; I am just too busy. So I guess this one
case I refer to the bill is still outstanding, because I got a call from a
Blue Cross full time CPO consultant that wishes to discuss the bill. I did
hear of this event happening before to another CPO, and when it happened to
me I was not surprised. It seems the other CPO was being asked to downgrade
a code below Medicare rates because the consultant thought the charge was too
expensive. I imagine (since I was not privy to the conversation) that the
consultant took the manufactures items cost, hopefully added for design
consideration in the prosthesis, the install time, and graded the
effectiveness to adjust the component for function, and figured a price he
thought was appropriate, again as I am told a price below Medicare Rates.
Well, I was surprised. I am not sure what finally happened. The consultant
happens to be //////////////////,CPO. I don't know if his call is to verify
the seriousness of the case reflected by the charges; I had to use a
flex-foot preparatory, and a custom Tec Liner, all with a laminated socket;
or about how the patient is getting along. If /////////CPO is there for
Quality Assurance for the patient, or a gatekeeper for Blue Cross on
professional pricing or both that's fine. As long as he is objective. I do
believe Blue Cross most likely would want to lower their cost, so the
discussion with ///////, CPO will be informative, and I sincerely hope a
compliment to our profession, as opposed to being a negative.
CPO

I absolutely agree with you. It's becoming more and more difficult to
provide service and receive appropriate reimbursement while proceeding under
the letter of the law in terms of following legal protocol when billing for
services after services were rendered and hoping you'll receive proper
compensation. Many insurance companies, however, still consider your first
encounter with the patient/client as the date of service, wherein you can
bill for the anticipated final outcome after this visit and before you've
actually invested all your time and componentry costs in a venture on which
you are unsure of reimbursement amounts, (Medicare excluded, of course.)
   And furthermore, the insurance company practice of negotiating fee
discounts after the claim is submitted is an unacceptable! I like to ask the
claims adjuster who requests this foolishness, How would you feel if at the
end of your work week, your employer came up to you and asked if you'd accept
20% less salary this week in order for your paycheck to be processed?
   I would think that the insurance companies who utilize this concept should
be under government investigation for fraudulent practice!
Barry Steineman, CPO
President, The Ohio Chapter, AAOP


   This is an area where this forum can really help everyone in this industry
change the way insurance companies deal with O&P claims. If we collectively
let the insurance industry know that we expect different responses, we will
begin to change the way that they deal with our claims.
   We have had moderate success with commercial & HMO insurance, with the
following approach:
   Once the assessment is completed, the proposed Care Plan is entered into
the computer to create a claim. Instead of a date of service, we have
modified our system to accept the letter p to signify planned services.
The claim for planned services and a cover letter explaining our requirement
for preapproval of the Care Plan prior to performing services is sent to
the insurance company. Because the insurance industry already recognizes the
Care Plan terminology and is used to having to approve them for other
services, I believe that we have hit upon a path of least resistance to
achieving this goal. It is important that once an approval is received, that
you update the computer. To preserve our Usual & Customary rates we post an
adjustment to the charges as a contractual obligation reduction. Once work is
completed, the date is entered into the claim and it is sent on paper with a
copy of the approval letter.
   While this front loads the work on the billing staff, they are working on
claims before you have time & materials tied up in a patient that you may
never be paid for. It also turns the patient into an advocate for you, with
their own insurance company, because they are waiting on their insurance
company so that they can receive your services. Once the work is completed,
payment is much faster.I hope this helps everyone.
Pat Shannon
President/CEO
Healthcare Management Solutions, Inc
The Nations O&P Billing Service
402-898-0561 Fax 402-898-0564
<Email Address Redacted>