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Are we responsible for payment because the doctor did not get prior authorization?

I received a question from a follower that I need help answering. She askes "My husband is on Medicare and has AARP as his supplement.  He had a procedure done by a cardiologist. I am just now finding out that the insurance would not pay for this because the doctor did not get prior authorization. My question is: are we responsible for this payment because the doctor did not get the approval first?"

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Honored Social Butterfly

There has been some changes to original Medicare in this area - there are now some Hospital Outpatient Services that require prior authorizations but I don't see anything that would be considered an actual "cardiac" procedure. 

CMS 06/15/2020 - Prior Authorization for Certain Hospital Outpatient Department (OPD) Services  

Who also told you that the denial was due to NOT getting prior approval?  I am asking this because sometimes it is just a terminology thing - what did the Medicare EOB say about it?   There are other reasons claims could be denied because the doc or his staff coded something wrong or the diagnosis did not relate to the procedure.  OR perhaps such a procedure is only covered once ever so often under preventive care but the doc wants it done again, not as preventive, but as a diagnostic tool.

 

Without more info - it is all a guess - you gotta dig deeper into the Medicare "weeds".

 

It's Always Something . . . . Roseanna Roseannadanna
Bronze Conversationalist

@GailL1  if the OP has original Medicare and a supplement the MSN would provide details on why the claim was denied.   But if they have an Advantage plan the details would be in the EOB.

 

The list of medical services requiring prior authorization under original Medicare are situations that often would be considered cosmetic, and therefore not medically necessary.

https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf

 

I still think the patient has an Advantage plan vs original Medicare and a supplement.


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Honored Social Butterfly

Sorry my lingo is rather generic - Explanation of Benefits EOB is the same to me whether original Medicare or Medicare Advantage private insurer.

The OP said that there was a "supplement"  I took this to mean a supplemental plan (Medigap) - but yea, you are right could be just a vocabulary confusion.  The OP post is confusing like you said.

 

Yes, those new Medicare prior auth. things are mostly cosmetic things but if you think some of them aren't medically necessary, I'll let you have a conversation with a friend of my mom's who's eyelids droop so much she is pretty much blind.

That's why there is a prior approval procedure for these things because they could be medically necessary.

But like I said to the OP - they aren't cardiac procedures.

I am sure that if the OP gives us more info, we could probably figure it out.

It's Always Something . . . . Roseanna Roseannadanna
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@cougarlinz your post is a bit confusing.

 

Original Medicare does not require prior authorization except when DME is involved. Most Advantage plans will require prior authorization for some tests or procedures. If you or your provider don't submit details for approval prior to the event, the claim can be denied.

 

You said he has "AARP as his supplement".

 

A supplement plan is a secondary payer and pairs with original Medicare.

 

An Advantage plan provides benefits and claims admin. Advantage plans are PRIMARY, not secondary payers and are not a supplement plan. Advantage plans do not coordinate with Medicare.

 

If your Advantage plan denied the claim and refuse to reconsider on appeal, then you (the patient) ARE responsible for paying the provider.


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