Prior Approval?
Frank Vero
Description
Collection
Title:
Prior Approval?
Creator:
Frank Vero
Date:
6/19/2014
Text:
In light of all the questions regarding billing, authorizations, audits and such, I would like to share this discussion I recently received.
................................
At the policy forum I was astounded that this keeps coming up.
Simply put, prior approval is only used to determine benefits and coverage of the patients insurance plan, it is not a guarantee of payment.
With so many different plans and combinations of benefits that the insurance companies offer, the prior approval process is used to make sure what coverage is in place under that particular patients plan. The patient presents a card from Aetna and the provider
calls to see if what they plan to do is covered, do they have the silver, gold, platinum or diamond plan. The provider finds out that all the patient has is the 5K lifetime cap basic mineral plan and that cap has already been met. It's a determination of
benefits process, that's it, is not a guarantee of payment. We already know the coverage available through Medicare, what's the point?
Having received prior approval from the insurer you are still subject to claim audits and medical review by the insurer. Read your provider agreements and review state insurance law, there is no guarantee that you won't be audited and held accountable for the
insurer medical policies you need to meet and records you are required to keep.
Prior authorization has been proposed as a potential solution to RAC audit issues. In order for it to have any chance of affording any protection it would have to be designed as a 100% prepayment audit, not prior approval. Even wIth the prevalence of Medicare
prepayments audits today some of those same claims are again subjected to a RAC audit.
The power wheelchair folks have a 90+ day wait period at a minimum. Do you think we would want a wait period on the new amputee when we are already complaining about the 100 days in SNFs. The wait in power wheelchairs may be tolerable because these patients
are simply changing from a manual mobility tool to a powered mobility tool which confers no therapeutic deadlines. We are about mobility and any delay in care compromises our patients success.
What am I missing?
................................
At the policy forum I was astounded that this keeps coming up.
Simply put, prior approval is only used to determine benefits and coverage of the patients insurance plan, it is not a guarantee of payment.
With so many different plans and combinations of benefits that the insurance companies offer, the prior approval process is used to make sure what coverage is in place under that particular patients plan. The patient presents a card from Aetna and the provider
calls to see if what they plan to do is covered, do they have the silver, gold, platinum or diamond plan. The provider finds out that all the patient has is the 5K lifetime cap basic mineral plan and that cap has already been met. It's a determination of
benefits process, that's it, is not a guarantee of payment. We already know the coverage available through Medicare, what's the point?
Having received prior approval from the insurer you are still subject to claim audits and medical review by the insurer. Read your provider agreements and review state insurance law, there is no guarantee that you won't be audited and held accountable for the
insurer medical policies you need to meet and records you are required to keep.
Prior authorization has been proposed as a potential solution to RAC audit issues. In order for it to have any chance of affording any protection it would have to be designed as a 100% prepayment audit, not prior approval. Even wIth the prevalence of Medicare
prepayments audits today some of those same claims are again subjected to a RAC audit.
The power wheelchair folks have a 90+ day wait period at a minimum. Do you think we would want a wait period on the new amputee when we are already complaining about the 100 days in SNFs. The wait in power wheelchairs may be tolerable because these patients
are simply changing from a manual mobility tool to a powered mobility tool which confers no therapeutic deadlines. We are about mobility and any delay in care compromises our patients success.
What am I missing?
Citation
Frank Vero, “Prior Approval?,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/236480.
