NHIA Reimbursement Training Center

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Insurance Verification and Authorization Process

Insurance Verification and Authorization processes are crucial elements of the Reimbursement process.  Failure to efficiently perform these tasks may result in Bad Debt and Revenue loss.

Insurance Verification begins with obtaining basic information
    • Demographics:
      • First/Last Name (accurate spelling is essential)
      • Permanent Address information
      • Date of Birth
    • Insurance Name (the patient may have more than one plan)
      • Verify patient name (or subscriber name) matches insurance ID card
      • SSN, Medicare Number and/or Member Number, Group Number
      • Employer as applicable
    • Diagnosis
    • Start of Care date (or estimate if hospitalized)
    • Therapy Type including
      • Drug name(s), strength, dose, frequency and duration
    • Once basic information has been obtained verification of insurance can be initiated. 
 
Insurance Verification Processes should be consistent and should generally be performed as follows
    • Determine where/how the insurance can be verified.  Most payors have the option of Interactive Voice Response (IVR) system and web capability.  There are also practice systems with built in eligibility verification and/or clearinghouses with verification capability.  The most efficient method for the payor and for your business should be chosen. 
    • Verify benefit information on all insurance plans provided by the patient, discharge planner or hospital.  If the patient has Medicare and a second commercial plan it is important to determine which plan is primary.
      • If Medicare is primary you must ask/determine if the commercial plan will only pay after Medicare makes payment (the deductible and/or co-insurance is paid by the commercial plan – this is a “supplemental” plan,   or
      • If the commercial plan will pay even when Medicare denies – this is a “true secondary” plan.
      • Note that the secondary may require authorization.
    • Verify the effective dates and whether the patient is active and eligible for the therapy/drug being provided
    • Ensure that the payor does not confuse Home Infusion with traditional “Home Care” which is consists of “skilled” nursing or therapy services such as OT, PT, etc.
      • Homebound status is not required by the majority of payors for Home Infusion patients.  If you are told that “the patient must be homebound”, ensure the payor knows that the patient is not receiving traditional home care. 
      • If the payor is contracted, explain that the homebound status is not a requirement of the contract.
    • Ask if the drug/therapy is covered under the patient’s Major Medical, DME, Home Infusion and/or a prescription drug card/part D Plan.
      • Infusion benefits will generally fall under Major Medical Benefits, however they may also fall under the DME and/or Home Care benefit portion of the patient’s plan.
    • If the plan is a Third Party Administrator (TPA), ask/determine the name of the plan that will ultimately be paying the claim.
    • If unknown and/or not provided within the contract ask where the claim should be sent (paper remit address and/or electronic payer ID) and if there are filing limit restrictions.
    • If you are unsure whether a contract exists with the payer, provide the NPI and ask if they show the NPI as In-Network (INN) with the plan.  Obtain both INN and Out of Network (OON) benefit information.
      • Deductible, coinsurance, copay and stop loss amounts and how much of each has been met year to date.
      • Note that certain insurance plans may require a separate contract for “DME”.  Enteral may fall under the DME benefit for some patients.
    • If you have more than one location, ensure you are verifying information and/ or obtaining authorization under the correct NPI/ tax ID. 
    • COBRA (Consolidated Omnibus Budget Reconciliation Act) plans premiums are paid monthly by the patient.  Failure on the part of the patient to pay the premium may result in termed insurance.  COBRA allows for a 30 day grace period so it is possible for the patient to be eligible at the start of care and then be retro termed for lack of payment.  It is important that COBRA plans are verified monthly.
    • Workers Compensation plans will require the date of injury, the diagnosis(s) related to the case, and the case number (it is a good idea to obtain the case worker’s name as well).
    • ACA Plans (aka Obamacare, Exchange, Marketplace) and Individual plans require monthly premium payments by the Insured.  Subsidized ACA plans may have a generous grace period but will be retroactively terminated if premium payments are not paid.  It is important to verify the date the premiums are paid through.  Insure that premiums are paid through the date of service.  For ongoing or long term therapies, reverify monthly.
 
Insurance Re-Verification Processes

Re-verification may be necessary in the following situations:

    • Patient is discharged and returns to service.
    • Medicare patients that have been off service or who have not received shipment for more than 60 days.
    • Patients with COBRA benefits.  Suggest verifying monthly. 
    • Patient has a Managed Medicare (MA, MAPDP) plan.  Suggest verifying monthly, or as frequently as beneficiary is allowed to change plans.
    • Part D plans.  Suggest to run a test claim for each new NDC dispensed.
    • High dollar patients (IGG, Inotropic, Factor) patients.  Suggest verifying monthly.
    • All patients.  Suggest verifying at least once per year (when patients plan year ends, usually in December/January)
    • ACA Plans (Obamacare plans) and Individual plans.  Suggest verifying monthly.  Verify the date the premium is paid through to insure coverage on the date of service.
 

Some plans allow beneficiaries to frequently change insurance plans.  Be sure to verify coverage as often as they are able to change plans.

Authorization Process

Every effort should be made to obtain an authorization prior to or at the time of service.  The Authorization should cover all dates of service (payors will provide authorization for a week up to a year).  All separately billable drugs, per diems and nursing codes should be authorized.

Prior Authorization is not always a guarantee of payment.  Regulations may vary by state. To protect against denials:

    • Insure verification of coverage for each service to be provided was obtained and properly documented. 
    • Insure clinical documentation supports the diagnosis and medical need for the service provided.
 

For specialty drugs and high dollar therapies, review the payer’s medical policy to determine if criteria for coverage is met.  Medical policy often can be found on the payer’s website. If no published medical policy is available:

    • Determine if FDA guidelines support the service based on patient clinical criteria.
    • Request a Pre-Determination of coverage from the payer.
 

A Pre-Determination is a request to the payer’s medical staff to review the clinical documentation and make a coverage decision in accordance with the payer medical policy and the insured’s plan benefits. Pre-Determinations may take as long as 30 to 45 days.  Services provided with a favorable Pre-Determination of coverage are unlikely to result in denials for medical necessity.

Authorization Tips/Notes:

    • Plans will rarely “retro” authorize Home Infusion; therefore requests not made at the time of service. When unavoidable delays occure, such as a weekend or Holiday should be made the Monday following the weekend referral, the day following a holiday, or within 24-48 hours of the start of care.
    • If the therapy will be long term, request an extended authorization period to maximize the authorization period based on the physicain order.
    • If the main therapy (drug) has ended, but the patient still requires catheter maintenance, you may request authorization for the catheter maintenance.
    • Authorization and re-authorization should be entered and tracked using the Authorization Process, often within your practice managment system. 
    • Documentation of the requested items should be made in a specific area of your system for each patient.  Detail the authorization request, to include:  Date span requested, items, codes, quantity/ units, Intake ID or Reference Numbers, how the auth was requested (verbal, fax, portal) and any pertinent contact information.
    • If an authorization is requested via fax or a payor portal, follow up to check the status of the authorization within 48-72 hours of the request.
    • If a payor states “no authorization is required”, request a reference number for the call and notate the name, department, phone # and the time of the call.  It is suggested that you notate the codes and start/stop date even though an authorization was not obtained.
      • Call to verify whether authorization is/is not required at the “stop date” you entered.
      • If the patient is a Medicare “bill for denial” patient, take extra care to ensure the payor understands that you are not asking for authorization on the 20% coinsurance.  Explain that Medicare will be paying “0” on the claim and that you will be looking to the other payor for payment.
 

It is suggested that all Insurance plans be verified to determine eligibility and benefit/coverage information prior to the patient being accepted on service.  Patients should be notified of their financial responsibility and payment options should be discussed prior.

Re-Authorization and Revised Authorization Process

Prior Authorizations can be issued for a length of time, a defined number of treatments, a defined number of billing units, or any combination of criteria.

Insure that a process is in place to monitor authorizations for any revisions that may need to be made during the patients course of therapy due to order changes. 

Examples:

    • Change in billing units due to a dose increase. 
    • Change in medication
    • Change in frequency of dosing
    • Route of administration
 

Reevaluate the Authorization after a hospitalization, may require an extension and/ or authorization for wastage.

Insure a process is in place to request re-authorizations prior to the end date and in the case of extended therapies.

Re-authorizations may require updated clinical information to support continued service. Example: lab values, results of diagnostic procedures, physician notes, nursing visit notes, etc.