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pvacanti

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41
Location
Lake Odessa, MI
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Hello! I'm trying to figure out how other specialist offices who round on and accept consults from the hospital and end up doing surgery obtain prior authorizations from insurance companies that require an authorization for the surgery. By the time the charges for the consult and surgery make it back to the office we are already past the 72 hours window that the insurance company will allow a retro authorization. I feel that because we are being requested to consult the patients by the hospital and the patient was in a observation status the insurance company should not require a prior auth for the surgery because it wasn't an scheduled in advance. I hope that makes sense:) Is anyone else having this issue with denials by insurance companies for no authorization on a patient that was admitted to Observation at a hospital?
 
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In my experience the hospital obtained it. If it was emergent such as they came in through the ED/admitted to obsv and required surgery there are usually exceptions. I have also encountered times we we had to appeal and show the surgery was not "planned", "elective" ahead of time.

I think it depends on the group and the hospital relationship as well.
 
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Thank you for your reply! I would think that there would be exceptions as the patients do come in through the ER. This is not first claim denied for this and I have attempted to appeal and they also get denied. I wanted to confirm that I was billing the correct POS (22) or should it be ER POS (23)?
 
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pvacanti said:
Thank you for your reply! I would think that there would be exceptions as the patients do come in through the ER. This is not first claim denied for this and I have attempted to appeal and they also get denied. I wanted to confirm that I was billing the correct POS (22) or should it be ER POS (23)?
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It depends on the surgery/procedure CPT being billed and the disposition of the patient at the time of service. There could be a lot of different reasons for denial.

This is older but could help. https://www.ama-assn.org/system/files/2021-04/pa-state-chart.pdf
 
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