Patients, providers and staff alike are frequently frustrated by chiropractic pre-authorizations. But unfortunately, the process is likely here to stay and, in many states, getting much more common.
After all, by installing chiropractic pre-authorizations, insurance payers create an effective way to block the patients from truly accessing the benefits they have paid for and, simultaneously, setting you (the contracted provider) up to get the blame for not navigating their system when it happens. Of course, this is all done in the name of “medical necessity” or “cost containments” or “preventing unnecessary treatments” or some other noble-sounding goal.
So what’s a doctor to do who wants to get their patient the care they need? For insurance plans with a chiropractic pre-authorization process in place, in most cases, your only chance is to jump through the hoops set up by the payer and hope for the best.
Of course, those who are frustrated with the whole game, often ask questions in a different direction. In other words, are their exceptions or alternate routes to getting around chiropractic pre-authorizations (or similar programs for other services)?
Today, we are going to talk about that concept:
The Rule: No Chiropractic Pre-Authorization, No Payments
The operating rule for plans that have a pre-auth process in place is very simple: if you do not obtain the required pre-authorization, the claim for those services will be denied.
This is the plain and simple way that plans can offer many visits to patients on the surface; but underneath, it enables them to pay for much fewer. In other words, a plan may say the patient has 24 chiropractic visits per year (subject to pre-authorization). But if the insurance only approves 6 visits, then the other 18 will go unused by the patient (and will not be reimbursed by the payer). Sneaky and oh so effective!
Exceptions to Chiropractic Pre-Authorizations
With every rule, there are exceptions and the pre-authorization process is no different.
The most obvious exception is on the payment side. If you are a contracted provider and don’t obtain pre-authorizations, your payment is denied and a provider write-off is issued. Put simply, this means you cannot charge the patient for any denied services that you rendered.
On the other hand, if you are NOT a contracted provider (ex: out of network) and you fail to follow the pre-auth process, your claims will also be denied. However, you can pass the cost of those denied services on to your patient. Since you are not a contracted provider, you are not obligated to accept the insurance company’s reimbursement as payment in full.
Beyond the “obvious exception” of in vs out of network payment options, there are other potential exceptions to the chiropractic pre-authorization process. Not many chiropractors know about these exceptions and there a couple that may come in handy.
While each payer may have slight variations to their “exception list” this example from a Blue Cross Blue Shield payer is very typical of what kind of extenuating circumstances can be considered a legitimate exception to NOT obtaining a pre-authorization. My comments are in italics after the exception is listed.
- Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
The situation does occasionally arise where your patient started down the route of being a self-pay, only to change their mind and want you to bill the insurance. If this is the case, you may think you are sunk when you find out that there is a pre-authorization clause in place. But according to this common exception, you could actually apply for the care to be approved after the fact. (And even if it doesn’t work, hopefully the patient already paid you, so this is a win-win opportunity!)
- Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
This hopefully doesn’t happen often, but this offers hope for chiropractic clinics in Houston and similar areas affected by natural disasters where it was physically impossible to operate business normally.
- Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
Unfortunately, this happens frequently. Your staff goes through the pre-auth process, but the claim gets denied because of no record of it. This clause gives hopes that you can appeal the denial by showing evidence that you did, in fact, attempt to obtain the chiropractic pre-authorization.
Alternate Routes to Authorization
There are additional alternate routes or strategies that may be employed when you have a pre-auth policy in place but these are more specific to the particular plan or policy in question.
In fact, if you have ANY insurance plans in your area that require pre-authorization, it’s imperative that you have an effective and efficient strategy in place otherwise you will potentially lose time, money and patients by not taking proactive steps.
Interested in Alternative Strategies to Navigate Pre-authorization Plans? That’s just one of the many topics I’ll be teaching at my upcoming Smarter Chiropractic SEMINARS, in Seattle and Portland. Join us to stop working harder and start working smarter in 2018 and beyond!