Do YOU demand Pre-authorization?RESPONSES (part 1)
Randall McFarland, CPO
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Title:
Do YOU demand Pre-authorization?RESPONSES (part 1)
Creator:
Randall McFarland, CPO
Text:
Here's the ORIGINAL POST
One thing that frustrates me when trying to verify coverage, is when the
insurance company refuses to divulge how much they'll actually pay. Instead,
they say that the billing will be subject to review by the medical
committee AFTER we submit the invoice.(Which means AFTER we have already
provided our services)
In our attempt to be upfront, we prefer to forewarn our clients as to what
their anticipated financial responsibility will be so there will be no
surprises. This is impossible to do when we are expected to proceed without
any assurance (let alone guarantee) as to the benefits that will be covered
by the insurance company.
I recall hearing that Medicare has plans for a preauthorization hotline of
sorts and this will hopefully prevent many of the denials and reviews we are
experiencing while waiting to be paid for work we performed months prior. In
California, we also have the TAR system for Medicaid.
With other (non-contracted) pay sources, there is sometimes pressure on us
to proceed before it's totally clear what we'll be paid. As I have learned
to not to accept every discount a payor asks for, I'm starting to realize
that I shouldn't have to accept a policy of after the fact decisions on our
reimbursement.
I suppose that there will always be providers who will blindly accept
whatever the insurance company asks for (be it discounts or refusal to verify
benefits), so if I take a stand on an issue, they may just go down the road
to someone more desperate for work.
I have heard of memo billing or pre billing for services to determine
if (and how much) the insurance company will actually pay for services. If
this is a legitimate practice, is there a proper protocol that should be
followed? (I know this is not allowed for Medicare)
Do you agree that it should be LAW that ALL insurance companies/payors be
required to disclose their coverage to us BEFORE the invoice for services
rendered is submitted?
I will post responses. Please include your title and state, but put your
name in parentheses if you wish to remain anonymous.
Randy McFarland,CPO
RESPONSES (separated by a blank line) Thanks to all respondents!!
I wholeheartedly believe that it should be common practice or law, if
necessary, for the insurance or Medicare or Medicaid payer to tell us before
we
do the work if they will pay. Including what percentage of the billed amount
it
will pay for the services. Since we have contracts we know what the allowable
will be already. Way to many times we have gotten burned by payers saying the
patient is covered but only when the bill is submitted do we realize the
patient
was covered only to $1000.00 of the amount. Or worse covered for some items
based on diagnosis. Some insurers call things DME, others orthotics,
prosthetics,
and external prosthetics. For this reason I developed a procedure whereby I
have
a person call to verify coverage (and coverage termination date), deductibles,
copays and office visit payments on each and every patient that walks in the
door
both when eval'd and moments before delivery. Yes, its a pain in the ass.
Yes
it irritates the patients who think they have coverage. Yes we discover many
don't have O or P coverage. We make the person at the insurance company dig
for
answers and we take names. Eventually I hope the checker on our end will be
able
to formulate a matrix of who does what in what plan with what IPA so that the
waste of resources is minimized. This is also complicated by the fact that
some
IPAs are capitated and responsible for the payment in some plans and not in
others from the same insurance company. CRAZINESS.
I think Medicare is easier to deal with but it still has its pitfalls
because
patients lie about the same and similar issues. And Medicare will not
divulge
any information. It almost seems like a conspiracy on their part to defraud
US!
In a perfect world we should not be the coverage police. Medicare should pay
us
and THEY should go after the patient if they run afoul of the regulations. The
doctor wrote the script, we should be paid for filling it. Again the perfect
world. Anyone out there have a Congressman or Senator in the family? Anyone
know
George W.
I also believe that insurance companies do not know what it is we do.
Doctors
have told me they get stiffed sometimes. If we get stiffed for part of an
hour in
labor we can live with it just like all health care providers. But when we
get
stiffed for components that is a different matter. Hell, the MDs don't even
realize or care about that issue.
One other thing. All independent owners, especially in SoCal are having
this problem I'm sure you will agree. I believe independent business owners
should convene a summit meeting and discuss this openly to formulate a
response
plan to payers that makes sense to them. It may even increase the payers
bottom
line. Unfortunately I don't believe this will ever happen because each owner
is
too protective of his contacts and contracts, and his billing and AR
methodology,
whether it works or not. If you did you may give the competition an edge.
Additionally, one owner on his own will not undertake the issue because what
he
may accomplish will benefit the competition without them being involved.
I would love to unravel this issue but even my employer holds his cards so
close
to the vest I am left to only speculate.
Board Eligible Prosthetist
The patient needs the product and service and should expect that their
insurance will cover a majority of the expense.
One thing I find myself relating to the patient is that he is responsible
for the payment regardless what the issuance company pays. I have returned
checks for ridiculously low amounts to the insurance company and billed the
patient separately with an explanation of their behavior. Most patients see
the insurance company as the bad guy and pay us for services rendered and
then get reimbursed from their carrier.
For those who refuse and say we agreed to accept payment from their
insurance company we show them where they agreed, in writing and in three
separate statements, that they are finically responsible for any claim
amounts not covered.
Of course, prearranged discounts and agreements are immune to these terms.
The bottom line with this problem is when you are trying to deal with an
insurance company, that you are not contracted with, the contract is ONLY
between the insured and the insurance company. Fact of the matter is, they
don't have to even answer the phone when we call! The only positive
solution to the problem will be when we finally, individually, decide that
enough is enough, and stop accepting assignment. That will put the problem
squarely where it belongs.
Every patient that I've ever known, and this includes me, wants to pay
minimum premiums and get maximum benefits. When they have to cope with the
realities of dealing with the financing of their own care, things are sure
to change. Unfortunately, one of the changes will be that not nearly as
many prostheses/orthoses will be replaced and those that are will be after a
longer period of time.
When you look at it from the insurance side, the minute that a provider
knows what the level of reimbursement is going to be, that gives them
license to shoot for the stars. Not everyone does that, but there are a
bunch who do.
I believe that you need to get your patients involved from the very
beginning and make them aware of the language that insurers use, what it
REALLY means and then tell them that if they don't want a very unpleasant
surprise, they need to get with their insurance company and find out exactly
what the terms of their policy say with regard to the provision and payment
for a prosthesis/orthosis.
CPO, LPO Florida
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
One thing that frustrates me when trying to verify coverage, is when the
insurance company refuses to divulge how much they'll actually pay. Instead,
they say that the billing will be subject to review by the medical
committee AFTER we submit the invoice.(Which means AFTER we have already
provided our services)
In our attempt to be upfront, we prefer to forewarn our clients as to what
their anticipated financial responsibility will be so there will be no
surprises. This is impossible to do when we are expected to proceed without
any assurance (let alone guarantee) as to the benefits that will be covered
by the insurance company.
I recall hearing that Medicare has plans for a preauthorization hotline of
sorts and this will hopefully prevent many of the denials and reviews we are
experiencing while waiting to be paid for work we performed months prior. In
California, we also have the TAR system for Medicaid.
With other (non-contracted) pay sources, there is sometimes pressure on us
to proceed before it's totally clear what we'll be paid. As I have learned
to not to accept every discount a payor asks for, I'm starting to realize
that I shouldn't have to accept a policy of after the fact decisions on our
reimbursement.
I suppose that there will always be providers who will blindly accept
whatever the insurance company asks for (be it discounts or refusal to verify
benefits), so if I take a stand on an issue, they may just go down the road
to someone more desperate for work.
I have heard of memo billing or pre billing for services to determine
if (and how much) the insurance company will actually pay for services. If
this is a legitimate practice, is there a proper protocol that should be
followed? (I know this is not allowed for Medicare)
Do you agree that it should be LAW that ALL insurance companies/payors be
required to disclose their coverage to us BEFORE the invoice for services
rendered is submitted?
I will post responses. Please include your title and state, but put your
name in parentheses if you wish to remain anonymous.
Randy McFarland,CPO
RESPONSES (separated by a blank line) Thanks to all respondents!!
I wholeheartedly believe that it should be common practice or law, if
necessary, for the insurance or Medicare or Medicaid payer to tell us before
we
do the work if they will pay. Including what percentage of the billed amount
it
will pay for the services. Since we have contracts we know what the allowable
will be already. Way to many times we have gotten burned by payers saying the
patient is covered but only when the bill is submitted do we realize the
patient
was covered only to $1000.00 of the amount. Or worse covered for some items
based on diagnosis. Some insurers call things DME, others orthotics,
prosthetics,
and external prosthetics. For this reason I developed a procedure whereby I
have
a person call to verify coverage (and coverage termination date), deductibles,
copays and office visit payments on each and every patient that walks in the
door
both when eval'd and moments before delivery. Yes, its a pain in the ass.
Yes
it irritates the patients who think they have coverage. Yes we discover many
don't have O or P coverage. We make the person at the insurance company dig
for
answers and we take names. Eventually I hope the checker on our end will be
able
to formulate a matrix of who does what in what plan with what IPA so that the
waste of resources is minimized. This is also complicated by the fact that
some
IPAs are capitated and responsible for the payment in some plans and not in
others from the same insurance company. CRAZINESS.
I think Medicare is easier to deal with but it still has its pitfalls
because
patients lie about the same and similar issues. And Medicare will not
divulge
any information. It almost seems like a conspiracy on their part to defraud
US!
In a perfect world we should not be the coverage police. Medicare should pay
us
and THEY should go after the patient if they run afoul of the regulations. The
doctor wrote the script, we should be paid for filling it. Again the perfect
world. Anyone out there have a Congressman or Senator in the family? Anyone
know
George W.
I also believe that insurance companies do not know what it is we do.
Doctors
have told me they get stiffed sometimes. If we get stiffed for part of an
hour in
labor we can live with it just like all health care providers. But when we
get
stiffed for components that is a different matter. Hell, the MDs don't even
realize or care about that issue.
One other thing. All independent owners, especially in SoCal are having
this problem I'm sure you will agree. I believe independent business owners
should convene a summit meeting and discuss this openly to formulate a
response
plan to payers that makes sense to them. It may even increase the payers
bottom
line. Unfortunately I don't believe this will ever happen because each owner
is
too protective of his contacts and contracts, and his billing and AR
methodology,
whether it works or not. If you did you may give the competition an edge.
Additionally, one owner on his own will not undertake the issue because what
he
may accomplish will benefit the competition without them being involved.
I would love to unravel this issue but even my employer holds his cards so
close
to the vest I am left to only speculate.
Board Eligible Prosthetist
The patient needs the product and service and should expect that their
insurance will cover a majority of the expense.
One thing I find myself relating to the patient is that he is responsible
for the payment regardless what the issuance company pays. I have returned
checks for ridiculously low amounts to the insurance company and billed the
patient separately with an explanation of their behavior. Most patients see
the insurance company as the bad guy and pay us for services rendered and
then get reimbursed from their carrier.
For those who refuse and say we agreed to accept payment from their
insurance company we show them where they agreed, in writing and in three
separate statements, that they are finically responsible for any claim
amounts not covered.
Of course, prearranged discounts and agreements are immune to these terms.
The bottom line with this problem is when you are trying to deal with an
insurance company, that you are not contracted with, the contract is ONLY
between the insured and the insurance company. Fact of the matter is, they
don't have to even answer the phone when we call! The only positive
solution to the problem will be when we finally, individually, decide that
enough is enough, and stop accepting assignment. That will put the problem
squarely where it belongs.
Every patient that I've ever known, and this includes me, wants to pay
minimum premiums and get maximum benefits. When they have to cope with the
realities of dealing with the financing of their own care, things are sure
to change. Unfortunately, one of the changes will be that not nearly as
many prostheses/orthoses will be replaced and those that are will be after a
longer period of time.
When you look at it from the insurance side, the minute that a provider
knows what the level of reimbursement is going to be, that gives them
license to shoot for the stars. Not everyone does that, but there are a
bunch who do.
I believe that you need to get your patients involved from the very
beginning and make them aware of the language that insurers use, what it
REALLY means and then tell them that if they don't want a very unpleasant
surprise, they need to get with their insurance company and find out exactly
what the terms of their policy say with regard to the provision and payment
for a prosthesis/orthosis.
CPO, LPO Florida
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
Citation
Randall McFarland, CPO, “Do YOU demand Pre-authorization?RESPONSES (part 1),” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 17, 2024, https://library.drfop.org/items/show/217089.
