← The coder, offshore RN, or if you’re lucky, pencil pushing generalist who doesn’t practice anymore will tell you that you don’t meet medical criteria for a procedure they can’t even technically render under their medical license. ← SUPER common…and usually the information is there…this is actually the most common stall tactic you will seeĭoesn’t meet “medical criteria” AKA medical necessity. ← Again, rare, but for unusual cases they may require certain procedure codes (e.g., gender affirming surgery, lipectomy, etc.) ← Rare, but they do actually think over there sometimes and alert you if you have an old plan Of course, the answer can be “no,” it’s not covered. They’ll approve cases for patients without active coverage at times, because again…why make anything logical in the land of medical billing. ⚠️#PitfallAlert#⚠️ – Covered doesn’t mean paid in full or paid at all…it doesn’t even mean the patient has active coverage! All the payers do is look at medical necessity…that’s it. Sometimes you get a letter, rarely you get a call and oftentimes you need to call them to remind them to communicate and they give the auth number over the phone. When insurance says “yep, all good,” the request is approved and the provider receives an authorization number. Oh and each carrier uses them slightly differently…because why make anything simple or easy in the land of medical billing?īasically, the patient needs the A-OK from their insurance company that the medical request is absolutely necessary and will be covered after adjudication (fancy shmancy industry lingo for processing your claim). This is called authorization, prior authorization, prior approval, or precertification, prior notification, etc. When a patient is told by their health care provider that they need medical treatment, a prescription drug, or a health care service, the insurance company must approve it before the patient moves forward in many cases. So What are Medical Billing Authorizations? The reality is the assumed responsibility for the entire authorization process lands on the provider/provider’s office…so best know how to handle it. ![]() Try telling that to your patient as you send them a bill and see what happens to your online reviews though. The patient is actually technically responsible for ensuring prior notification and approval are on file ahead of surgery. Whose responsibility is it to get that procedure pre-approved by insurance?ĭid you guess the MD? You’re technically wrong, but in all actuality you are correct. Here’s a question for you: A doctor tells a patient they need to schedule a procedure.
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