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With the help of our dedicated team of front office management specialists, you will have a measurable impact on the day-to-day operation of your office and improve customer satisfaction.
We provide full front desk support for healthcare providers, including all necessary tasks related to managing administrative tasks.
Common Procedures That Require Preauthorization
Many insurers require patients to obtain referrals from a primary care physician before seeing a specialist. Hospital admissions that don’t come through the emergency department often require preauthorization by insurers. Additionally, imaging studies like MRIs and CT scans often require preauthorization or something called “prenotification,” which is more involved than a referral, but less onerous than a pre-authorization. These processes result in an authorization number that providers must use on claims submitted for payment.
Providers have different policies about what they do when a patient doesn’t have a referral, preauthorization, or prenotification. Some providers postpone treatment until proper authorizations are obtained, while others may go ahead with a procedure and try to retroactively get authorization.
The Key to a Smooth Preauthorization Process
The best way to smooth the preauthorization process is for medical billing personnel to be prepared with the correct CPT code for the anticipated services. Of course, it’s not always possible to determine the exact CPT code before a service has been provided. Communication with the physician is essential so you can learn what procedures he or she anticipates performing. It’s best to learn all possibilities rather than risking that a procedure will be performed without preauthorization. In other words, it’s better to authorize treatment that ultimately isn’t given than to perform a procedure without preauthorization and risk not being reimbursed.
In an emergency situation, patient coverage may not be known before the physician encounter. In these situations, providers are required to contact the insurer as soon as possible after the fact to obtain any necessary authorization.
What Can Happen if You Don't Get Necessary Preauthorization?
When services are provided without expected preauthorization, what happens next depends on the insurer and the specific policy under which the patient is covered. Some insurance plans state that if a patient seeks services requiring preauthorization, but doesn’t obtain preauthorization, the patient is liable for covering the payment. If a provider neglects to obtain preauthorization and payment is denied by the insurer, it may come down to absorbing the cost of the treatment or trying to collect it directly from the patient, neither of which are good options.
The burden of obtaining pre-authorizations is on the provider because patients don’t know CPT codes and may not know when preauthorization is (or might be) required. Double-checking up front whether preauthorization is required may take some extra time on the front end, but with WMB teams of experts, it can save significant time trying to chase down claims and payments and prevent having to absorb costs for procedures that weren’t preauthorized.
Benefits of using WMB Prior-Authorization Services:
Pre-approval processing can typically take several days, but a proactive team like WMB can help reduce the time it takes to obtain and process pre-approval.
With WMB (Wise Medical Billing) Team,
Please do not hesitate to contact us today for a quick call consultation or a demonstration of our services.