Discontinued Authorization and Payments: How to Respond

Posted by Jenn Munson on Oct 2, 2018 8:00:00 AM
Jenn Munson

Should you worry about getting a letter from a payer asking for information about your facility’s services? Short answer: yes!      

Let’s assume that your facility is licensed to treat behavioral health issues in adolescents in a residential setting. However, that setting happens to be a wilderness program. Does the setting automatically mean that your program isn’t providing treatment at the level-of-care guidelines that payers require?     

Depending on how you respond to requests from payers for information about the services you provide, the payer could decide that your facility is not meeting its level-of-care guidelines and can refuse to authorize services, stop paying claims, and even request takebacks on previously paid claims.

This is what has been happening in many areas of the behavioral health sector over the past few years, and it impacts programs beyond those focused on adolescents. Carriers like Optum are systematically reviewing programs and requesting information to determine alignment.

Do not take these letters from carriers lightly

Once your facility loses authorization from a payer, the impact can be devastating to your revenue and your ability to help your patients.    

Every payer’s level-of-care guidelines have important requirements and criteria that you need to understand before you can represent your services accurately. If you simply respond with information that does not show your alignment to the guidelines, the payer could deny authorization and payments for your services … regardless of whether you are actually following the payer’s guidelines or not.

To align or not: that is the question

You need to determine whether your facility’s phases of care align with the level-of-care criteria for the carrier. Consider turning to a third-party insurance and billing professional with deep expertise and experience in working with payers and facilities to confirm whether your services align or not with an individual payer’s guidelines.

If they don’t align, then you’ll need to make some strategic decisions about whether you want to bring them into alignment or not. The time to do that is now.

Be proactive, don’t wait to get a letter

Click here to get help with responding to carrier letters for information or suspension of authorization and payment

If you are unsure whether your facility aligns with the level-of-care guidelines from the carriers that you bill, a prudent course of action would be to engage an expert before you receive any letters requesting more information or suspending authorizations.  

That way, you can already take any necessary actions required to align with the carrier, make informed decisions, consult a lawyer if necessary, and be better prepared to respond in the most effective way to achieve a positive outcome for your facility.   

Would you like help with the data and analysis for determining if you are getting the best value from your billing outsourcer?  Please click the button below to download the Elevated Billing 5 questions document.

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