It’s a well known fact in the medical billing world that insurance companies will do everything possible to delay payment on a submitted claim. That’s the main reason it’s essential to make sure the claim is submitted correctly the first time. Of course, human error is well within the realm of probability. However, some errors will not be forgiven on the insurance provider end, which will directly affect the bottom line of a healthcare facility.

Authorizations for a procedure are required before being performed on a patient. This includes but isn’t limited to some office visits, in-office procedures, overnight stays, surgeries, et cetera. It’s vital to get the authorization before the patient even shows up to the facility for their appointment. If a procedure is done without prior authorization and the insurance carrier doesn’t cover such a service per the patient’s insurance policy, the physician and the practice will not be reimbursed for services rendered. One may surmise the amount is something that can be turned over to the patient, making it their responsibility. After all, you did something for their health so why shouldn’t they cover it? Here’s why: because your facility didn’t take the proper steps to make it their responsibility. As a result, it now becomes the liability of the facility that provided the medical service to improve the well being of their patient.

During the authorization process, the medical professional working with the insurance provider may discover that a procedure will not be covered. There’s no need to panic! Well … unless the patient is standing right in front of you, ready to kick some butt because the information wasn’t confirmed earlier, and wondering whether the procedure is going to be done at all. That would make anyone angry! Not to mention that it makes a facility look highly incompetent that everything concerning their medical situation wasn’t managed before the patient made all proper arrangements to be there for their appointment.

This part of the medical world is similar to any contract: The practice gives the patient the options for an appointment based on availability; the patient agrees to show up. Now, the practice takes care of everything else to ensure a smooth transaction between patient, physician, staff, and insurance company. If the facility doesn’t live up to its end of the deal, the patient has every right to be upset and possibly seek medical care elsewhere, which directly affects the bottom line.

If a procedure isn’t covered by the patient’s insurance policy, it’s not the end of the world. The facility has options. If presented to the patient beforehand and terms are agreed upon, the patient can make the cost their responsibility. However, they must be aware of the situation before they walk through the door.

Otherwise, the financial responsibility falls on the facility. If this issue isn’t resolved, the results can be harmful and revenue will be lost. While some may believe that physicians can afford the loss, others who have witnessed the declining reimbursements for services rendered feel differently. None of us want to work for nothing, and while this country only accepts money to pay overhead, we all have to work for a living. Let’s face it: if love, understanding, laughter, and charity could pay our bills the way it fills our soul, we would all be financially wealthy. Sadly, some medical professionals toil 80-hour work weeks just to pay the mortgage. Where’s the fun in that?

A facility needs staff trained to play by the rules established by the insurance company so the practice may keep finances in proper order. Sometimes things become so routine that a medical professional may take for granted that a procedure is covered because that insurance carrier has covered it many times in the past.

However, keep in mind that even though two patients may have the same insurance company, they don’t necessarily have the same policy. One person’s policy may have a higher co-pay; the other person’s deductible may be higher. Making a five-minute phone call to the insurance provider and getting the authorization necessary for reimbursement will erase all the worries of having the cash flow to cover rising monthly overhead. After all, bills don’t stop coming just because finances aren’t available to cover them. A simple solution would be to make certain medical personnel always walk the right path to ensure healthy patients and a healthy bottom line. It starts with making sure the authorization is there before anything is done.  

Minerva DeJesus and Auriana (Audi) Reyes founded Simple Solution Billing, a medical billing company in Orlando. They have a diverse medical background with more than 20 years of experience helping physicians control their finances while maintaining control of their practice. For more information on acquiring higher reimbursements for services rendered, contact SSB at simplesolutionbilling@yahoo.com. 

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