From authorization number to paid claim

2 min read

An authorization is not the objective. Payment is. Between them sits a step that is, in a great many practices, a person reading a number off a letter and typing it into a billing system. It is the weakest link in the chain and it is where revenue quietly disappears.

#The failure

A claim denies for no authorization on a service that had a valid authorization. The work was approved. The work was done. The claim does not pay, and it is appealed or written off. Nothing clinical went wrong and nothing in the authorization process went wrong; the number did not travel.

#Where it breaks

The authorization was obtained by one team and billed by another, with a letter or a message in between.
The number was recorded against the patient rather than against the specific encounter, and the wrong one was used.
The service was rescheduled outside the approved date range and nobody re-checked.
The approval was partial or modified and the claim billed what was requested rather than what was approved.
The procedure changed intraoperatively and the authorized code is no longer the performed code.

Partial approvals are the expensive one

An approval for six units billed as twelve denies, and it denies in a way that looks like a payer error rather than a practice error. The response said six. This is why the approved quantity should be stored as a field and checked against the claim, not read once and remembered.

#What good looks like

Store the authorization against the encounter
Not the patient. A patient can have several authorizations; a claim needs the right one.
Store the constraints as data
Certification number, effective and expiration dates, approved codes, approved units. Each as its own field, so a system can compare them to the claim.
Check before the claim goes out
Service date inside the window, billed codes within the approved set, billed units within the approved quantity. This is a mechanical check and it catches almost all of this category.
Re-open on any change
A rescheduled date or a changed procedure invalidates the fit between authorization and claim. Treat both as events that re-open the authorization question.

#Reading the remittance

When the 835 denies for authorization, read whether the payer is saying no authorization exists or that the authorization does not match. Those are different problems. The first may be a number that never arrived. The second is usually date, code or quantity, and it is fixable with the record you already hold.