Thanks to all who responded! A majority of
respondents do some or all of the options listed in
addition to giving the patient the option of paying
for the device and being reimbursed.
Choice C, having the patient wait, was most popular,
while choice B, delivering the device before auth is
obtained, was least popular.
There's no simple way to avoid the risks and hassles
of managed care, other than to share them with the
patient, giving them the option to:
1) take the risk of not being reimbursed, after paying
out of pocket, or
2) the hassle of waiting or coming back until auth is
The urgency and importance of the orthosis influences
the decision making process.
> Has anyone come up with an ingenious solution to the
> problem with walk-in referrals needing prior
> authorization through insurance but needing the
> ready-made orthosis the same day (for fractures for
> example)? It seems we either can:
> A) fit the patient, put the name on the brace, stick
> it on the shelf and call them when ready, hoping we
> will not compromise patient care;
> B) deliver the device risking approval will not be
> granted and we will not be paid; or
> C) make them wait in while the OA tries to obtain
> auth, disrupting workflow and holding up the
>Please respond A,B,C, or other with regard to your
> protocol and any additional comments. I will post a
> summary of replies.
> Thanks, Zach Harvey, CPO
There is no easy solution. I have been burned enough
not to risk giving the patient the orthosis without
auth. I give them two options , self pay and we will
reimburse them if auth is recieved, or they can wait
We make them wait, we have tried delivering the device
and getting auth
later, but it is a disaster, Patients get mad when an
We do offer them the option of paying for it, and
giving them a refund
when the payment comes from the Insurance.
If you find a better solution, I would be very
Answer D: Let the patient choose. The patient may pay
us for the
we will refund if the insurer approves and pays or the
wait for insurance approval.
Have the Dr's Admitt patients in the Hospitals and get
a P.O. and deliver the device. Or, inform your
refferal base of the problem and let them decide to
place the patient in a cast or if they have advanced
insight that the patient will need this in the future
write the rx at first contact and approve it for
future delivery. My exper. has been that a pre-
approval is good for up to 6 months.
D. All of the above.
"B" kind of...
Our facility has the advantage of being able to
fit/cast/measure on the
spot and deliver the device at a later time (option A)
as we are a
public hospital, and as such, we cannot charge
insurance agencies for our
clinical time. This means that, should approval be
denied, we lose some
revenue and time to the process, but the hospital is
happy with this
The only time it gets confusing is when the patient is
from a rural or
regional area and requires fitting on-the-spot. In
these cases we will
spend plenty of time on the phone trying to obtain
approval while the
patient is in the department. (option c)
Our third option- which we don't use very often, and
is not applicable
to private practice- is to bypass the insurance agency
and make the
hospital pay for the treatment. We do this by calling
a specialist into
the department to write a public referral (for which
the patient doesn't
have to pay), then all treatment is covered by the
hospital as a public
outpatient. Naturally, we like to raise revenue like
anyone else, but
we also value patient care. If this "bypass" route is
chosen, it is
generally for a patient who has special circumstances
and for whom the
treatment is much more important than the
I wish there was a more ingenious solution, especially
for those in
We give the patient the following options (assumming
you can't get
verbal auth right away....)
1) wait for auth before having patient take delivery
2) have patient leave a credit card impression or a
check if they wish
to have the orthosis whether or not it is authorized.
Then they can
have the orthosis immediately, which is what all want.
It is not a fabulous solution, but it works for us.
Remember you may be penalized by delivering before it
is authorized, or
payed at all. Put on shelf, have them come back or
pay cash. What if
auth has to be mailed/not faxed and there is a
penalty and they have a fracture?
I give patients choice of A or C or they can pay
themselves and we will
reimburse if ins. company pays. Don't do B unless you
are willing to
B and some C
I say go with (C) but let the patient talk directly to
agent. You do know that even if they authorize the
orthosis they may
claim they did not authorize payment for same?
We unfortunately use example C, unless the pt. has
which they must wait for prior authorization. Public
aid will only
prior auth over the phone if it is life or death. The
problem is for
fracture management waiting the 30days for public aid
usually means the
no longer needs the brace; but they will still come
get it. With our
fracture management we usually get prior auth from
most insurances by
time we are done with the fitting. If someone does
not want to wait
prior auth then we have a paper for them to sign
stating that auth was
needed and the pt has chosen not to go through
insurance; most pts will
In emergency situations choice B applies. In
non-emergency situations choice C applies and we take
cash, check, credit or debit cards.
There is one other option not mentioned. If the
patient is in a hurry, have the patient pay for the
item, (at the contracted rate if it is a contracted
payor with your business), and promptly refund the
patient's payment when/if you are paid for the item.
This way you do not lose, the patient gets the device,
and the patient gets their money back, less deductible
and/or copay when you get paid. If the patient is not
accepting this, you have the other three options. I
do not consider 'B' to be an option, because it puts
your business too much at risk. Just thoughts from
With managed care being what it is, the only practical
option is to have the patient wait until you receive
authorization to provide your services. They all know
how the process works and shouldn't be too surprised
at the wait. If you can't get a response in a fair
amount of time after having explained the
circumstances (patient on a gurney waiting in your
lobby), have the patient or a family member get on the
phone and make a BIG fuss. None of us can afford to
get stuck any more than we already are.
And if the patient doesn't like it, we give them the
option to self pay and be treated right away. If we
get it authorized, when overpayment is received we
mail them a refund.
Depends on how long the patient is prepared to, or
can, wait for
the prescribed device. If the patient absolutely must
have the device,
knows that it is in his/her best health interests to
have it, and
wait any time for prior approval, then they should be
willing to pay
up front and then take their chances on seeking
insurance plan later.
Each company must weigh how they can handle this
instances it is easier to have the patient wait for
the approval,or take credit
card payment as guarantee of payment. In most cases
the patient usually
ends up waiting for the approval because they still
that in the end they are still responsible for paying
for this item.
Depending on how you or your staff operate dictates
individually handle this vexing problem.
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