Payers might give you the wrong information

Documentation is best defense

Recently, a large payer denied a claim for a CT scan of the abdomen due to no authorization, even though a registrar previously had been told none was required.

“When we sent our appeal, we included the name of who we spoke to, the number we called, and the specific codes used in the call to determine coverage,” says John T. Porter Jr., access denial analyst for patient financial services at Scripps Health in San Diego. “The claim was overturned, and we were paid.”

The Appeal Resolution letter from the payer acknowledged that information had been provided indicating precertification was not required for the procedure. “We made it very easy for the payer to locate the error on their part. It resulted in a successful appeal,” says Porter.

At UT Medicine San Antonio (TX), the clinical practice of the School of Medicine at The University of Texas Health Science Center San Antonio, patient access staff members sometimes receive authorizations from payers, only to have the claim denied due to lack of authorization, says Dale Flowers, MBA, chief administrative officer.

“When the claim is appealed, the payer ‘finds’ the authorization,” says Flowers. “This type of incident is difficult to guard against, and it is difficult to put in processes that prevent it from happening. It ends up delaying payment and requiring staff resources for follow-up.”

When you call the payer to obtain an authorization, it’s not only what you say; how you ask the questions also is important, says Sandra N. Rivera, RN, BSN, CHAM, director of patient access at St. Joseph’s Wayne (NJ) Hospital and St. Joseph’s Regional Medical Center in Paterson, NJ. “Communication is not a uniform process between the payers and even different representatives who may receive the call at the payer sites,” she warns.

Many times, if a patient has a new plan, or recently married and is on the spouse’s plan, registrars might call the payer and the payer might state the patient is not on the plan, but the situation might not be so clear-cut, says Rivera. “This is often a matter of timing. It depends on when the payer last updated the database for the employer,” she says.

Payers sometimes inform registrars that the service does not require prior authorization when it does, or incorrectly state that a service is covered when it is not, says Porter. “Access staff is just given the standard ‘This is not a guarantee of coverage or payment,’ disclaimer, and the payer is protected against any wrongful representation of coverage,” he says.

If a service required prior authorization and it was not obtained, the claim will be denied and require an appeal or retro authorization to have the denial overturned, says Porter. If a service is excluded or has a limitation, the claim will be denied with the explanation of “non-covered service.”

“This is a more challenging denial,” says Porter. “There is a specific exclusion, and the standardized disclaimer usually states ‘exclusions may apply.’” Here are strategies to avoid denials involving incorrect information:

• Involve others as needed.

In some cases, patient access staff members have had continued problems with particular payers giving inaccurate information on same-day surgical cases, reports Rivera.

“We have had to call the employer to deal directly with the payer rep in charge of the benefit plan,” she says. “In other cases, we have had three-way calls between the patient, the physician office, and the facility.”

When payers inaccurately state an authorization is required, Flowers says this information is documented and shared with UT Medicine San Antonio’s Managed Care Operations department. “They communicate this to their contacts in the health plans, in hopes of curtailing this practice,” he says. (See related stories on how to collaborate with providers to avoid denials, p. 117, and what to document, p. 117.)

• Always ask if the service requires any kind of prior authorization or precertification.

“I’ve found the payer will not always volunteer that these benefits hinge on a pre-service action like an authorization or policyholder phone call to the payer,” says Porter. “You have to prompt them for the information.”


For more information on inaccurate information given by payers, contact:

Dale Flowers, MHA, Chief Administrative Officer, UT Medicine San Antonio (TX). Phone: (210) 450-0545. Fax: (210) 450-4924. Email:

John T. Porter Jr., Access Denial Analyst, Patient Financial Services, Scripps Health, San Diego. Phone: (858) 657-4048. Fax: (858) 657-4499. Email:

Sandra N. Rivera, RN, BSN, CHAM, Director, Patient Access, St. Joseph’s Wayne Hospital/St. Joseph’s Regional Medical Center, location?. Phone: (973) 754-2206. Email: