HEI Knowledge Center: Authorization Denials

Transcription

A common denial that we see, and I think everyone can relate to, is authorization denials. The EOB will usually say something along the lines of Pre-Certification, Authorization, or Notification Absent. The way we like to handle this issue, is to start with the simpler reasons as to why the claim denied first, and work our way out to the more complex reasons. We believe that this helps narrow down the denial reason without really overthinking the issue. We are really just applying the philosophy of Occam’s Razor, in which the simplest answer is usually correct.

Starting off, we will jump into our billing system and see if there was even an authorization billed out on the claim. This will lead us to a yes or no outcome. If yes, the authorization number is on the claim, I will generally go and check insurance portals, as almost every portal now has a section where you can go and look up the authorization just by typing in the number. In it, the portal will show you:

  • The physician that was authorized
  • The diagnosis
  • The CPT codes
  • The NPI
  • The dates of service that was authorized
  • (Etc.)

This could possibly be the reason as to why the claim denied, as we could have:

  • Authorized the wrong code
  • Had the wrong physician
  • Incorrect NPI
  • Or the DOS authorized were actually for an earlier visit

Now, going back to our yes or no outcome, if there was no authorization billed out on the claim, we will have to start digging a little deeper. We will look in the host system to see if the authorization number is there, and maybe it was just a simple crossover issue from our host system to the billing system. If we rule that out, we start going through the notes on the account, to see if there was any word as to why the authorization was not obtained or if it was possibly even denied. If it was denied during the time of service due to, for example, the stay was not deemed medically necessary, we might have to appeal or possibly convert the claim to be billed out for a lower level of care, depending on the circumstances.

If there was no authorization obtained whatsoever, then we will need to start asking additional questions such as:

  • Is this insurance in-network?
  • Was insurance verified during the DOS?
  • Was the patient retro added to the insurance?
  • Can we obtain a retro authorization?
  • Are we within timely, to get a retro authorization?
  • And- Do we have a good enough reason and proof to appeal for a retro authorization?

All of these questions will lead us to look deeper into where and why our process broke down. This leads us to understand how we can prevent this mistake from happening again in the future. It is one of the things we like to focus on, here at HEI, by working with our clients to reduce these issues from ever happening.

Finally, we are going to take all the information that we found, and put it into a scenario from our internal system, CollectLogix. We will choose the formal denial scenario and write out our  general notes to summarize our findings, explain why the claim denied, and what we are going to do to correct the issue. Next, we will choose the claim type and put in the reference number received from the insurance plan if you made a call. Document the date of the EOB and the claim number in the DCN box. Then mark the denial type (in this case we are using Auth / Precert denial), and check off the next two boxes as we investigated the denial reason and determined the origin of the error. Choose an option from the drop down menu for denial response, and check off the box for issued IPO / Reported Error, if you have determined that there is an issue or problem with the current process. Lastly, set your follow up days for when the account will drop back into the queue.

So just remember, when working with authorization denials, it’s best to start with the simplest answer to the solution, and work your way out from there. This method will make it much easier to narrow down not only the reason for why your claim denied, but also to pinpoint the issue in where your process had broken down and enable you to fix it.

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