Our provider-clients routinely satisfy or attempt to meet their contractually-required administrative burdens by requesting pre-authorization for scheduled services but are informed no prior authorization is necessary – then, later, they receive no authorization denials. Or worse, they receive no authorization denials on pre-authorized services.
Or, patients arrive for unplanned medical care either via direct admission by a physician for urgent admission or by way of the emergency room. Either way, providers routinely attempt to identify applicable insurance coverage whenever possible, as soon as practicable, to request authorization in accordance with contracts. If insurance information is known, many times, they are either left waiting for medical review to be completed while the unscheduled admission proceeds, or they are denied authorization altogether — or worse, they are told no authorization is required and led to believe services can proceed and will be covered, only to later be denied for no authorization. And, that is when insurance is known! If insurance information is not known at time of service, once providers become aware at a later date, they rush to notify payers of ongoing or discharged admissions only to be denied retro-authorizations for failure to request authorization in a timely manner.
Another common scenario, often masked by authorization denials, are denials for improper or missing notification of a patient’s procedure, visit, or hospitalization. Payers capitalize on the confusion surrounding ever-changing policy requirements regarding the differences between authorization and notification, leaving providers trying to figure out where they “went wrong”. Oftentimes, these “requirements” are contrary to both the law and providers’ contracts with payers.
- TGF forces payers to comply with state and federal laws, as well as applicable contracts, procedural guidelines, and health plan language