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    What happens when prior auths don’t match services provided?

    Obtain revised prior authorization and submit to payer as soon as possible

    Ray Painter, MDRay Painter, MD Mark PainterMark Painter


    I received a preauthorization from the patient’s insurance company, but the doctor turned in a charge sheet with different codes. This happens frequently. The claim was denied. Should I appeal?

    You are not alone. In fact, we see this issue more frequently as some payers are increasing the prior authorization denials from CPT code only to CPT code, number of units, and diagnosis code.

    Many payers will not accept appeals for payments when the prior authorization does not match the services provided. Instead, the payer will require that the authorization be changed to meet the services provided and then rebill the denied claim. Increasingly, payers are restricting the time allowed for a practice to revise these prior authorizations. It should be noted that most payers will allow reporting of fewer units or lower levels of service than have been authorized.

    Of course, the best way to avoid any issues with prior authorization is to obtain an authorization that accurately reflects what will be provided. For those cases in which the physician thinks more services may be needed or more units may be required, the authorization should include all potential services or should include the maximum number of units that may be used.

    Also from the Painters: How your practice can avoid medical necessity denials

    For those cases in which the prior authorization does not match the services provided, we recommend a process that requires the provider to communicate as soon as possible to the appropriate staff for change in prior authorization. (Note: This may not be necessary for encounters in which the units or the service level are below that which was prior authorized.) Billing of the encounter should be held until a changed prior authorization is obtained.

    We have seen many practices in which the solution to an incorrect prior authorization is to report the services that were authorized even when the medical record indicates other services were provided. For some cases, this may be the only way the claim will be paid. In these cases, we encourage you to exhaust all avenues of appeal and change in authorization to clearly notify the payer of what services were actually provided and the documented reasons for the service, accepting what you can in the end, and avoiding this in the future with the changes recommended above.

    Next: Billing for robotic partial cystectomy

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.


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