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AUTHORIZATION GUIDELINES/FEC

1/29/2013

 
--Prior Authorization is required for the following:
  • Division of the Blind
  • Veterans Administration
  • Vocational Rehab (appointments can only be booked by their staff, not by patients)
  • Tricare Prime (needs referral from PCP for any “medical” visits, pt must request fromPCP)
*** THE 1ST THREE WILL NOT ISSUE ‘SAME DAY’ OR ‘BACK DATED’ AUTH’S. 
AUTH MUST BE ISSUED PRIOR TO VISIT FOR EACH SPECIFIC PROCEDURE NEEDED.
 
--Prior Authorization or PCP Referral is required for SOME procedures for the following:
  • HMO plans (regardless of the insurance company) – some HMO’s require PCP referral, some procedures require prior authorization (i.e. plugs, lasers, injections, etc.)
  --Injections:
** Medicare does not issue authorization for any injection; however, documentation must show medical necessity.
  • < >Eylea, Jetrea, Lucentis, Macugen & Ozurdex:Billing MUST be notified– precertification may be required (every insurance plan is different)
  • All other injections:Please check with billing.Auth requirements vary depending on the insurance company & the patient’s individual plan.
  --Radiology Referrals (including MRI, MRA, CT, CTA)
** Medicare does not issue authorization; however, written scripts given to pt’s must include:
Pt Name, DOB, Proc Needed, Diag Code & if test is needed with or without contrast.
  • Most other insurance companies require Prior Authorization for radiology tests.Please complete appropriate paperwork and notify billing.Also, please find out what facility the patient would like the test performed at.  (Or at least what area of town they prefer.) Place of service IS required to get an authorization.
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ALL PATIENTS MUST CHECK OUT

1/15/2013

 
Patients are not to be told it is “ok” to leave after having certain diagnostic tests, i.e. Visual Field or OCT,  or even visits with our physicians without first checking out.  This is never acceptable.  Not even if the patient has their next appointment.

There is often the need to collect additional fees or to verify needed information.

All patients are to stop by check out (after receiving a service) prior to leaving.
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COPAYS, DEDUCTIBLES, COINSURANCE RELATING TO RETINA DOCTORS

1/15/2013

 
Applies to: Front Desk Receptionists, Front Office Leads, Clinic Leads, Retina Assistants

 This involves the collection of copays, deductible, coinsurance and previous balances as they relate to patients of our Retina Specialists, Drs. Ganiban and Vaishnav.

 Please do not go to Dr. Ganiban or Dr. Vaishnav and ask them questions like "Do you want us to collect this patient's copay or deductible."  Similarly do not write them notes like this on the Superbill.  They should not be put in the middle like this.  It is an uncomfortable place to put them.

 We have policies and procedures in place.

 Copays are to be collected.  Deductible is to be collected.  Prior balances are to be collected.  If you are unable to address these issues, contact a member of our billing staff - they are here to help. 

Again, do not place the doctor in the middle.  The doctor is here to examine and treat patients, not review billing statements.  If there is a need for a special/private discussion with one of the doctors about a particular patient, either myself or a member of the billing department can have that discussion.

Just because a patient may be having a planned procedure, i.e. an Avastin injection and there will be no level or visit charged, does not mean that the patient will not owe a copay.  Every insurance plan is different and there may be dozens of subgroups within a particular insurance with different rules on copays.  When you are unsure, call billing.

Never tell a patient there will be no copay or coinsurance for a particular day.  You do not know this.  No one knows this answer with certainty until the doctor has performed his examination, ordered tests, and/or performed a procedure, and even then, we often still do not know what will be assessed to the patient by their insurance company until the claim is processed.

 (NEVER PROMISE OR TELL A PATIENT "THERE WILL BE NO CHARGE OR COPAY.")

 Along with "healthcare reform," more and more of the costs associated with care are being shifted to the patients.  They do not in many cases understand this or why, and they are very frustrated and angry about this.  The proper explanation is that it is their insurance company that determines what their copays, coinsurance, and deductibles are, not our Practice...  but as participating providers we must honor our contract and collect all those amounts that the insurance company tells us are due.  It is the law.
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