Wiki DENIALS AND APPEALS

[andersont]

I am beyond frustrated. We have had several claims get denied because there wasn't an authorization. Getting an authorization is the person who is doing eligibility. Well, this new employee felt she didn't need to check eligibility for a while. So, of course, we would have to adjust these claims off. Well, the owner of this clinic says "no more adjustments". Everything denial will be appealed and if the payor still doesn't pay, we will contact the insurance commissioner.

We would lose the appeals if the issue was with our office not getting the appropriate authorizations.

What would you do?

Thanks

 

[TThivierge]

Hi
Ahh if the payer contract states that is the rule but it is your staff fault. This is the reason make the rules to save them money. I do not think want to get in tiff with your insurance payer by reporting them to the insurance commissioner. Just teach all register/access staff must verify insurance by online or phone call. Usually the payer gives you 72 hour to get this authorization done. Can you put flag on it or use the Microsoft outlook task remind it must be done by certain date?
I hope this data helps you
Lady T

 

[tbragg36]

I am beyond frustrated. We have had several claims get denied because there wasn't an authorization. Getting an authorization is the person who is doing eligibility. Well, this new employee felt she didn't need to check eligibility for a while. So, of course, we would have to adjust these claims off. Well, the owner of this clinic says "no more adjustments". Everything denial will be appealed and if the payor still doesn't pay, we will contact the insurance commissioner.

We would lose the appeals if the issue was with our office not getting the appropriate authorizations.

What would you do?

Thanks

Well depending on how long I've worked for the provider and his personality, I'd be looking at him like he's crazy.
First, I'd find out which payors I would be working with for a possible retro auth. Maybe, attempt to talk to the manager/supervisor of the auth department at the insurance company and explain the situation and ask them to please do a retro auth just this once. You might get lucky.
Second, I'd try to appeal the denial on the grounds of medical necessity (This could be a good appeal depending on the codes. Heart surgery over physical therapy could make a difference.)
Third, is the provider contracted with the insurance companies? There is a contractual obligation to adhere to the rules set forth by the insurance carrier, unless the provider happened to write a clause into the contract. Contacting the insurance commissioner and laying out that the provider neglected to follow the rules of the contract they signed would be a feeble fight.