I stepped in it big time this week. I was arranging a healthcare service for a family member. The hospital told me that a prior authorization was needed. I argued strenuously that no authorization was necessary. I went so far as to tell the hospital that I needed them to show me where it was written that the payer required an authorization.

The family member is enrolled in a Preferred Provider Organization (PPO) for insurance coverage. Typically, prior authorizations are not needed for members of a PPO. If the member utilizes network services, the service is covered; if out-of-network services are used, a portion of the cost is covered. I already knew the hospital was in-network with the payer.

I pushed back and I fussed. Two hours and several phone calls later (back and forth with the payer and provider), I had the proof in hand. I was wrong. Though most services need no authorization, the particular event I was trying to arrange had been carved out by the payer; yes, a prior authorization was needed.

Throughout the experience, I tried to at least get an appointment on the books. Nope, no way. The hospital would not grant an appointment without an authorization. Period. Once I learned that there was no choice and an authorization was needed, I worried that the authorization process would take too much time and I’d have to wait to get the precious number needed to arrange the service.

Again, no. The authorization was arranged in a flash by the ordering physician. Once I had the magic number, the service was promptly arranged. (I did make a couple more calls to apologize to all concerned for giving them a hard time and being such a pain in their neck.)

Here are the lessons for ambulance providers:

·         No service arrangement was made without the prior authorization, and,

·         The prior authorization took a moment to obtain

Every week, I visit ambulance providers who continue to make arrangements for service when they don’t know who the payer is, or, when they don’t know if an authorization is needed. The overwhelming concern is that the “facility will get upset” if payer questions are asked – or – that facility callers don’t know payer information.

The issue with facilities is a matter of ongoing education and outreach. You can adopt the approach taken by the hospital – if no authorization is in hand, no service will be arranged. This same approach can be taken with the Physician Certification Statement (PCS). If no PCS is available, no service will be rendered. Teach your facilities that this is how things work. Assuring that the necessary documents are in hand prior to giving service is not a new concept in healthcare.

I understand that patients have appointments, need service and must be moved to get to those services. But an authorization can be gotten quickly.  The service I arranged was just as critical to the health and well-being of the patient. (When an authorization cannot be obtained timely, there are often processes you can follow to expedite obtaining the authorization or to occasionally obtain it retroactively.)

The process of obtaining PCS forms and having the authorizations we need must improve. If providers don’t make strides in this area, then you will need to call people like me for the other most common problem we see – help with your accounts receivable. That’s when the organization’s accounts receivable has grown so large because ambulance companies are not getting paid for the services they provided.

Avoid the problem on the back end of your process. Don’t let your accounts receivable get out of hand. Start by having a better process at the front-end.

Let us know if we can help.

About the author:  Maggie Adams is the president of EMS Financial Services, with over 20 years’ experience in the ambulance industry as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to support their billing, auditing, and documentation training efforts. Check out our newest documentation training webinars and billing webinars on our website.Friend EMS Financial on Facebook, or for more info, contact Maggie directly at maggie@ems-financial.com or visit www.ems-financial.com