Some of the practices with whom I’ve worked had a similar statement. The practice had received an authorization for services that was not being honored by the claims processing department. There is actually a lot happening behind the scenes in that statement. Here’s how this unpacks.
The authorization is simply a ‘mother may I’. A nurse (sometimes not even with that qualification) reviews your request, any attached documentation, and the diagnosis code(s). If this quick review meets the guidelines the reviewer has in front of them, then an authorization is given.
The authorization does not allow one to waive the payer’s policies. If the policy for XYZ Insurance Company has a 90 day conservative therapy program, then you still need to order conservative therapy. The authorization likewise does not change any of the other medical necessity criteria that the policy may also include. It will also not override any plan exclusions that the policy may have.
If you do not have an authorization, the claim will not pay. That is one of the very first edits. However, having an authorization does not mean the claim will automatically pay either. The claim will still go through the normal edits that the insurance carrier has built into the system. If you received an authorization using ICD-10 code I87.2 but I87.2 is not a good diagnosis per the claims payment system, you will need to modify (if possible) the diagnosis code.
Finally, even if you have been paid with a good authorization in place, this does not mean that you cannot have monies recouped after an audit. If the audit determines that there was not sufficient documentation of medical necessity or conservative therapy, they can take back their monies. Showing that you had an authorization in place will not prevent this from happening.
As always, good documentation coupled with following the payer’s guidelines is your best protection against an audit.
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