Following the previous blog regarding pre-authorisation I was asked to explain what could go wrong even if pre-authorisation had been correctly obtained. To do so, consider this question against the background of a recent (within the last month) issue…
The patient provided the correct pre-authorisation for the initial consultation. The outsource company invoiced on behalf of the consultant and the consultant will be paid. Everybody is happy.
Say the patient requires further treatment, whether that is in the form of drugs or even a surgical episode is not actually that relevant. What is relevant is if the pre-authorisation only covers the initial consultation.
In other words, just because the patient has provided the right pre-authorisation, this does not in itself mean further treatment is covered by the same pre-authorisation. This is precisely what happened to an MHM client who forgot to advise the patient to re-contact their insurance company. A £656.75 rejected invoice later, the patient was horrified to have to pay the invoice even though she had obtained a pre-authorisation number.
Admittedly this is an extreme example but a patient is always best advised to re-contact their insurance company IF further treatment is necessary because otherwise it is assumed the treatment and therefore costs are covered. They may not be.
Furthermore some insurance companies offer an “Open referral policy” whereby it is mandatory for a pre-authorisation to be obtained. What happens if the insurance company has not been notified of subsequent treatment?? Read above, it could and does happen!