Have you ever requested authorization on a particular procedure (CPT Code) only to find out afterward there are additional codes or even a totally different CPT code than you requested?
It doesn’t help that only some payors allow for a retro authorization (auth)
and usually they have a short turnaround time.
Below are some tips from the MGMA Community.
From a Surgical Practice:
- Have the Surgical attendee to inform the Prior Auth. Manager or Coder as soon as the procedure is completed.
- The coder should compare procedure notes to the auth prior to billing.
From an ENT Practice:
- Have the physician give you all the possible CPT codes that could be performed and precert. them to be on the safe side.
From a Gastro Practice:
- Again request an auth. for all possible code combinations from the payor.
From an Ortho:
- Create a report that compares billed codes to approved codes.
- Then hold the claim for business days to make certain you have time to reach out to insurers and make adjustments.
- They have found that most insurers want it updated before they process the claim. Which is what the office wants also because it prevents refiling. Even if it takes additional months to get the prior auth. changed.
Summarized:
- Authorize all possible codes for the procedure.
Work with your insurance follow up team to identify our opportunities. This may lead to updates on how you order certain procedures. An update to both system and workflow.
- Timely charge capture. Because retro auth windows are short for some payors, it is imperative to understand if the codes being captured is different from codes authorized.
Same as #1. You have to assess how the charge lag is contributing to the denials.
- A process to compare codes being captured vs authorized and request retro auth.
This concept is for review before charges are submitted. Compare codes in charge sessions vs the codes authorized and flag sessions that have discrepancies so retro auth can be pursued.