Necessary Evil!
The American healthcare picture has increasingly become more
complex. The advent of the Affordable Care Act and other changes have ushered
in literally thousands of new healthcare insurance coverage options. These
options change all the time and each year new plans with new rules and
requirements spring up.
Arising within the new healthcare landscape has been the
necessary evil called the “Pre-Authorization.”
Medical Transportation
We will refer to “medical transportation” throughout this
post.
Our reasoning is simple.
Not all transportation for medical reasons is conducted in
an ambulance. While our billing office is heavily devoted to ambulance billing,
we also work on behalf of a number of clients that provide transportation by
other methods including wheelchair vans and vehicles outfitted to transport
persons on stretchers that are not ambulances, most commonly referred to as stretcher
vans.
Pre-Authorizations issued by insurance companies can affect
reimbursements for ambulance transportation and other modes of transportation
alike and affect the non-emergency/routine transport side of your line of
business. Emergency/9-1-1 trips are not affected by these rules in almost all
scenarios.
What is a Pre-Auth?
Like the name suggests, a pre-authorization is a form of
approval that the described mode of transportation is acknowledged by the
patient’s insurance company that they are aware that the transportation is to
take place.
It is important to understand that while for some
insurances, the pre-authorization is also a notification that reimbursement will
follow the transport; for other payers that may not be the case.
We find that many insurance companies will represent in the
“fine print” that the pre-authorization is not a guarantee for payment. Those
insurance companies provide written guidance that the pre-authorization, while
a required step on the path to receiving payment, is only one piece to the
reimbursement puzzle. Their guidance will further outline that the ambulance
patient care report or the report submitted documenting the transportation must
verify that the transportation has taken place and provide details of that
transportation scenario.
For the ambulance, the guidance will extend to explain that
a Patient Care Report must be submitted along with the claim to prove that the
patient met the insurance plan’s medical necessity guidelines.
Beware!
Beware! Not all pre-authorizations are created equal.
There have been numerous times that our EMS agency clients
have submitted a PCR to our billing offices accompanied by a pre-authorization
number which has been issued by the patient’s insurance and provided by a sending
healthcare facility.
However, the pre-authorization provided was obtained by the
facility for their services. We later learn that the pre-authorization was
never intended for the transportation of the patient only for the services
provided at the facility. Subsequently, the claim is rejected for payment as
the insurance payer is representing that they were unaware of and did not
sanction transport based on the pre-authorization provided to the facility.
In other cases, one pre-authorization covers all services
provided to the patient including transportation.
How do you know what is accurate?
Ask!
Unless you specifically verify (preferably in writing) the
services covered under the pre-authorization, you may not know for sure if
transportation is included.
Who obtains the pre-auth?
In almost all cases and with few exceptions, it is important
that the pre-authorization is obtained by the EMS agency that will be providing
the transportation service.
Of course, there are variations to this rule as there are
times as explained above that a facility may be granted a blanket
pre-authorization. But, it is important for the EMS agency to secure a
pre-authorization that is specifically intended to cover the patient’s
transportation.
Additionally, the very presence of the “pre-“ in
pre-authorization denotes that the approval should be obtained prior to the
transport. We strongly recommend that the pre-authorization be obtained in
writing (fax, e-mail, carrier pidgeon…) and be included with the supporting documentation
when the PCR is presented to your billing office. Your billing office, unless
in-house and part of the pre-trip scenario, cannot request and obtain a
pre-authorization after the fact.
Know Your Payers!
The key to successfully navigating the pre-authorization
maze is to know your payers well.
Learn the rules and expectations of the major insurance
players in your market.
If your EMS agency is a participating provider be sure that
you are aware of the pre-authorization rules for the plan you are participating
with. Be certain that you read the participation agreement carefully before joining
the network so you can educate your staff on the expectations.
Develop Standard Operating Procedures for your call-intake
and administrative staff to follow so all persons in the loop understand how to
request and successfully obtain a pre-authorization prior to scheduling the
transport.
The Ambulance Billing
Services blog is brought to you as an educational tool by Enhanced Management
Services, Inc. Enhanced Management
Services, Inc. is an all-EMS third-party billing contractor serving Fire/EMS
agencies across the United States. To
learn more about who we are and what we do, please visit our website at www.enhancedms.com and click on the “Get Started” button on
any landing page.
