potential post
Doug
Description
Collection
Title:
potential post
Creator:
Doug
Date:
8/26/2015
Text:
Afterthe unbelievably inspirational meeting in Baltimore this (Wednesday, 8/26/15)morning, I’ll offer some comparatively mundane comments but ones that I thinkare relevant as the environment evolves.
Outcomesare important in every arena. The outcome of pre-service communication with athird party entity needs to provide value. The semantics of pre-authorization,authorization, pre-certification, pre-determination, and so on have becomeirrelevant. These terms only document one’s ability to process through theadministrative hoops. That ability is obviously important but when those termsare used by (or directed to) a payer, a provider, or a supplier with thestandard disclaimer of “this does not constitute a guarantee of payment” a badsituation for everyone is created.
Knowingwhat a third party will pay on behalf of the patient is what allows appropriatebusiness to transact. I hope small business (folks like me), big business(Hanger, POINT, Reliacare, etc.), AOPA, BOC, etc. will help our industry moveforward. True cost containment with quality care will only occur when payers,providers, and suppliers work together fairly. Orthotists and prosthetists should be treated fairly and with the samegood faith with which they care for their patients.
Ihave had some success using the following when I receive the standard,meaningless “authorization” that contains the statement “this authorization isnot a guarantee of payment”:
“Irequest your determination of coverage for your referenced insured. Pleaseconsider all plan provisions/terms for pre-existing conditions and medicalnecessity for the ordered services as they relate to the noted diagnoses andprocedure codes. Also include in your determination the status of deductiblesand co-pays for the date you process this request, and any implications of ournetwork status of participation.
Specifically,what will your guaranteed payment to us be and what will be your terms ofdisbursement if the insured is eligible for your coverage on the date ourservices are rendered?
Thankyou in advance for your timely response. Your response will allow us toexpeditiously service the patient in good faith.”
Thepayer will always do the determination; it just needs to be done pre-servicenot post billing. The patient and provider of O and P services deserve usableinformation. There is a significant cost to the orthotist and prosthetist inproviding service and the financial responsibility for the patient has to beunderstood up front so appropriate decisions can be made. When a third partypayer is involved, accurate and reliable facts are what matter.
DouglasVan Atta, CPO
Outcomesare important in every arena. The outcome of pre-service communication with athird party entity needs to provide value. The semantics of pre-authorization,authorization, pre-certification, pre-determination, and so on have becomeirrelevant. These terms only document one’s ability to process through theadministrative hoops. That ability is obviously important but when those termsare used by (or directed to) a payer, a provider, or a supplier with thestandard disclaimer of “this does not constitute a guarantee of payment” a badsituation for everyone is created.
Knowingwhat a third party will pay on behalf of the patient is what allows appropriatebusiness to transact. I hope small business (folks like me), big business(Hanger, POINT, Reliacare, etc.), AOPA, BOC, etc. will help our industry moveforward. True cost containment with quality care will only occur when payers,providers, and suppliers work together fairly. Orthotists and prosthetists should be treated fairly and with the samegood faith with which they care for their patients.
Ihave had some success using the following when I receive the standard,meaningless “authorization” that contains the statement “this authorization isnot a guarantee of payment”:
“Irequest your determination of coverage for your referenced insured. Pleaseconsider all plan provisions/terms for pre-existing conditions and medicalnecessity for the ordered services as they relate to the noted diagnoses andprocedure codes. Also include in your determination the status of deductiblesand co-pays for the date you process this request, and any implications of ournetwork status of participation.
Specifically,what will your guaranteed payment to us be and what will be your terms ofdisbursement if the insured is eligible for your coverage on the date ourservices are rendered?
Thankyou in advance for your timely response. Your response will allow us toexpeditiously service the patient in good faith.”
Thepayer will always do the determination; it just needs to be done pre-servicenot post billing. The patient and provider of O and P services deserve usableinformation. There is a significant cost to the orthotist and prosthetist inproviding service and the financial responsibility for the patient has to beunderstood up front so appropriate decisions can be made. When a third partypayer is involved, accurate and reliable facts are what matter.
DouglasVan Atta, CPO
Citation
Doug, “potential post,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 25, 2024, https://library.drfop.org/items/show/237617.
