I’ve been asked this question quite a few times over the years.
In by far the majority of cases, your patient should obtain pre-authorisation prior to the initial consultation.
But sometimes, the patient arrives for the consultation and hasn’t obtained a pre-authorisation from his/her insurance company. First question: should you see the patient?
Yes of course you should; patient care must come first.
But the patient does not have a pre-authorisation! It does happen, it shouldn’t but in the real world it does. How should you handle it then? Ask the patient to ring his/her insurance company and obtain the pre-authorisation as soon as they possibly can. But….
If say the consultation was on July 8th and the patient does not call the insurance company until July 15th, the patient should make sure the insurance company know when the consultation took place.
In this example, the patient did not tell the insurance company it was a week earlier and thus when MHM tried to invoice, it was declined as the consultation was before the date upon which the pre-authorisation was issued.
If the patient holds an insurance policy, which will not allow the backdating of a pre-authorisation you’ll have even more difficulties. In which case an invoice for the initial consultation should be sent to your patient. This is not the insurance companies being unreasonable.
If you think about it, the patient has incurred a liability on behalf of the insurance company, which the insurance company knows nothing about. Ultimately the patient is liable for the consultation fee of course thus the invoice is sent to the patient. The patient rings up (normally quite upset) and points out they are insured and are indeed covered for consultations in their view.
Numerous phone calls between the patient, the insurance company and the outsourced billing company later, the issue will be finally resolved. The invoice is submitted to the insurance company and its paid in full.
It would have been paid a lot quicker and without the hassle IF the patient had been asked when they made the consultation appointment to advise their insurance company the consultation was for a specific date.
Generally speaking that is the cause of the issue:
Nobody told the patient he/she should speak to their insurance company and get a pre-authorisation.
If this is happening to you, it’s an issue that should be addressed and prevented otherwise you may spend 15 – 30 mins just sorting this one small problem out!