Your ASC's surgery scheduler has just scheduled a procedure for next week. Prior to performing this procedure, there are numerous steps required to ensure that your ASC is properly compensated for services performed. Pre-authorization — also called precertification, prior authorization, insurance verification and prior approval — from the patient's payer is just one vital phase in guaranteeing the optimal reimbursement available for your center.
This first in a two-part series provides five steps to take to help ensure you obtain payer pre-authorization.
1. Prior to contacting the payer, be sure you have all the necessary information:
- Full name
- Address
- Social Security number
- Date of birth
- Carrier identification number
- Group/contract/plan number
- Name of planned procedure
- Scheduled date of procedure
- Name of provider/surgeon
- Diagnosis
2. Contact payer (insurance company, adjuster, employer, etc.) to verify benefits at least two days prior to procedure but not more than 14 days prior (as benefits may change). For add-on patients scheduled on the day of procedure, verify benefits prior to the time of procedure.
If a patient has secondary insurance coverage, verify this coverage as well. Verification of secondary insurance coverage for patients with Medicare as primary insurer is usually not required.
3. Contact payer by telephone or online (if available) and verify/obtain the following information:
For Commercial Insurance
- Name of insured
- Name of patient and if covered under insured's contract
- Date of birth of patient
- Social Security number of patient
- Social Security number of insured
- Contract number, group number, plan code, etc.
- Eligibility of coverage (i.e., contract still in force)
- If in force, effective date
- If not in force, date of termination
- Type of coverage (e.g., HMO, PPO, POS, indemnity)
- If applicable, deductible amount and how much met (including any per occurrence deductible)
- If applicable, any copay due
- Amount of coverage (e.g., 80 percent paid by insurance, 20 percent owned by patient)
- Out-of-pocket patient responsibility
- Lifetime benefits — ask if close to being utilized
- Pre-existing condition clause
- Second opinion required
- Expiration date of pre-authorization
- Exclusions to policy
- If applicable, name of network or repricing organization
- If precertification is necessary. If so, obtain pre-cert number from insurance company or physician's office.
- If facility is not participating in contract, get in- and out-of-network benefits.
- Name of person at insurance company that gave you the information
- Date verified
- Address where claims are to be sent
For Medicaid or State Aid Program
- Name of insured
- Name of patient and if covered under insured's contract
- Date of birth of patient
- Social Security number of patient
- Social Security number of insured
- Contract number, group number, plan code, etc.
- Eligibility of coverage (i.e., contract still in force)
- If in force, effective date
- If not in force, date of termination
- Expiration date of pre-authorization
- If precertification is necessary. If so, obtain pre-cert number from insurance company or physician's office.
- Copay, if applicable
- Name of insurance company
- Date verified
- Address where claims are to be sent
For Workers' Compensation
- Name of employer
- Name of patient
- Social Security number of patient
- Claim number
- Date of injury
- If coverage in effect on date of injury
- Insurance carrier name
- Local agent, if applicable
- Name of adjustor
- Expiration date of pre-authorization, if applicable
- Address where claims are to be sent
4. Notify business office manager/administrator immediately if patient is ineligible for coverage or if there is any deviation of coverage such as non-participating contract or large deductible needing payment plan.
5. After pre-authorization is complete, if monies are owed by the patient (e.g., copays, deductibles, self-pay), provide information to the patient financial counselor so the patient can be contacted about financial responsibility prior to procedure.
Remember that pre-authorization of the procedure only means that the insurance carrier agrees that the planned procedure is medically necessary. Pre-authorization is not a guarantee of payment. Coverage may depend on many factors such as eligibility, deductibles, copays, participation of provider, out-of-network and in-network benefits, proper billing and timely submission of claims.
Also, pre-authorization requirements vary from payer to payer. Due to these many variables, it is important to perform accurate and thorough verification of payer benefits.
Note: Part two of this two-part series on improving upfront collections will share steps ASCs can take to provide more effective financial counseling to patients.
Caryl Serbin, RN, BSN, LHRM, is president and founder of Serbin Medical Billing, an ASC revenue cycle management company. Serbin Medical Billing's primary objectives are to provide the best coding, billing and accounts receivable management services available to ambulatory surgery centers (hospital joint-venture, corporate-owned or independent) and anesthesia providers. Ms. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.