How To Understand Professional Medical Billing: No Authorization Claim Appeals
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How To Understand Professional Medical Billing: No Authorization Claim Appeals

When we as providers participate with the insurance we accept the insurance payment as payment in full.

This information on claim reprocessing, no authorization and claim appeals is intended to help medical billing professionals and is not intended for the general public.

Getting paid by the insurance company is one thing but getting paid the right amount is another thing. Here is how to get the right amount paid to your doctor’s office and what to do when things go wrong.

Here are some things that you can say to the insurance company: 1) Do you know why we are not getting paid our par amount? (Par means in-network and an in-network doctor, surgeon or hospital facility will get paid more than an out of network doctor, surgeon or hospital facility.)

 

According to our contract, we should have been paid $$$_(X amount of dollars.)

  1. Okay the problem wasn’t that there was no authorization number, there just wasn’t a surgeon’s claim on file.

  2. So what I did I called the surgeon’s office to make sure they are billing for the same date of service and made sure that if it was inpatient the surgeon is billing for inpatient and not outpatient billing. So I made sure the inpatient or outpatient was correct.

When we participate with the insurance company you only leave the account open for the balance the carrier owes us.

The Medicare 20% is the EOB or Explanation of Benefits will show that there is a balance of the 20% after Medicare and then you can file to the secondary Medicare with the first Medicare EOB.

If the pre-certification number is denied or deemed not medically necessary then call the surgeon and see how they are handling the claim or if they got paid. Does the surgeon have a billing office, if so get a letter from the Primary Care Physician as he is the one that requested the procedure.

Call the PCP or Primary Care Physician and try to get a letter to confirm that this is the doctor’s patient. If this is not the doctor’s patient in the meantime you have to bill the patient no authorization. Then if the patient calls you need to tell him that he needs to get a letter of medical necessity from his PCP.

If the insurance company says that they will not pay a claim because there was no authorization number call the surgeon and get an authorization number then tell the insurance carrier that this service was an emergency and see if that works.

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