Prior Authorization, Post By: Teresa McPherson, CEO

 

In today’s world of so many insurances to choose from and not really knowing which one is the right plan for your care can be confusing when it comes to choosing a plan.  Some insurances plans such as HMO’s may require a prior authorization for any services to be rendered.  I would like to take a few minutes and help our current and potential patients understand what a prior authorization is:

Pre-Authorization

Pre-authorization is a term used for obtaining prior approval from your insurance before having a procedure or service done.  We here at Central Florida Pain Management try to make sure we obtain authorization that is needed prior to services being rendered so you can receive services that are needed for your care.

Insurance Denial and Appeals

Sometimes even with a prior authorization on file a provider can still receive a denial for services that have already been rendered to the patient.  A denial means that the insurance company has decided not to pay for the procedure or other service that your doctor recommended or preformed due to many reasons such as the insurances own medical necessity guidelines which may not be met (yes, that’s correct your insurance can decide what services are acceptable over your own doctors recommendations) based on the procedure to be performed, related diagnosis code and how many times the patients may have already received this type of service already .  There are even some still pre-existing policies out there as well.  We here at Central Florida Pain Management strive to try and make sure that any services that require a pre-authorization are obtained and meet your insurances guidelines.  However even the most diligent providers office can still be denied payment for some services.  Sometimes the provider can appeal with a letter and medical documentation to convince the insurance company to change their decision and provide coverage for the service.   However in some cases if the provider is participating with the insurance plan and the appeal is denied the provider does not receive any reimbursement for the services that were provided to the patient.  It is not only important for your doctor’s office to understand your insurance plan and what it will and will not cover but it’s also just as important that the patient understands what plans/polices they are choosing to sign up with.  Only with both parties informed can the doctor and patient make the right decisions together for any future care.

Post By:  Teresa McPherson, CEO