I’ve been asked this question quite a few times over the years.
In by far the majority of cases, your patient should obtain pre-authorisation prior to the initial consultation.
But sometimes, the patient arrives and hasn’t obtained a pre-authorisation. First question: should you see the patient? Yes.
Patient care must come first.
But how should you handle it?
Ask the patient to ring the insurance company and obtain the pre-authorisation as soon as possible. But….
If say the consultation was on February 8th and the patient does not call the insurance company until February 15th, the patient should make sure the insurance company know when the consultation took place.
In this example, the patient did not tell the insurance company it was a week earlier. When MHM tried to invoice, it was declined as the consultation was before the date upon which the pre-authorisation was issued.
If the patient holds an insurance policy, which will not allow the backdating of a pre-authorisation you’ll have even more difficulties. In which case an invoice for the initial consultation should be sent to your patient.
Is the insurance company being unreasonable?
No. It is not.
If you think about it, the patient has incurred a liability on behalf of the insurance company. However, the insurance company knows nothing about. Ultimately the patient is liable for the consultation fee of course. That is why an invoice is sent to the patient.
The patient rings up (normally quite upset) and points out they are insured and are indeed covered for consultations in their view.
Numerous phone calls between the patient and the insurance company later, the issue will be finally resolved. The invoice is submitted to the insurance company and its paid in full.
It would have been paid a lot quicker and without the hassle IF the patient had been asked when they made the consultation to advise their insurance company the consultation was for a specific date.
Generally speaking, that is the cause of the issue:
Nobody told the patient he/she should speak to their insurance company and get a pre-authorisation before the consultation.
If this is happening to you, it’s an issue that should be addressed and prevented. Otherwise, you may spend 15 – 30 mins just sorting this one small problem out!
pete@medicalhealthcaremanagement.co.uk