Wiki Ordering Provider

[cvand1972]

Hi,
We all know that Insurance companies require authorization for certain services and that authorization has to be generated by the ordering physician. One of my physicians is thinking of offering this idea to PCPs - if a PCP wants the patient to have a service done that requires an authorization, and the PCP doesn't want to get the authorization, my physician is willing to declare himself as the ordering provider and get the authorization.

I'd like to hear any thoughts on that. I'm having a hard time wrapping my head around that one.

I can't find anything that says an ordering provider has to see the patient before ordering a test.

 

[camillecoder@hotmail.com]

Wow. I hope he means that he would take responsibility for evaluating and treating whatever condition warrants a pre-authed diagnostic. He needs to demonstrate medical necessity and I don't understand how he could do that without having evaluated the patient. Off the top of my head here's one guideline that says that's a no-no.

Medicare Benefits Manual
Chapter 15
Section 80.1
Clinical laboratory services
must be ordered and used promptly by the physician who is treating the beneficiary as
described in 42 CFR 410.32(a), or by a qualified nonphysician practitioner, as described
in 42 CFR 410.32(a)(3)

 

[LouiseR1]

I agree, if the PCP doesnt want to get the authorizations his or herself, in order for your MD to get the authorization most insurance companies require clinical information that your doc may not have given that they have never seen the patient before.
We are a specialist office as well and if the PCP doesnt want to get the auth for us, our protocol is our provider requests an appointment to see them first so we can get the clinicals needed to get that authorization. Most companies require recent ekgs, recent blood pressures and they will even ask when the ordering doctor last saw the patient.

Louise