Q&A: Authorization denials

October 2, 2017
Medicare Web

Q. How can we work toward avoiding denials related to authorization issues?

A. Denials related to authorization issues are common and may occur for one of the following reasons:

  • Lack of authorization
  • Failure to notify a health management organization (HMO) or at-risk medical group of an admission from the emergency room
  • Authorizations for a different level of service
  • Lack of, or inconsistent, daily certification

Providers should ensure that all scheduled procedures or non-emergent admissions are authorized or certified prior to services being rendered. For unscheduled or emergent admissions, HMOs require authorization of services and notification of admissions from the emergency room once the patient has been stabilized. Preferred provider organizations (PPO) may also require an authorization or initial certification for the service or admission, along with daily clinical certification throughout the stay. Failure to do so can prompt a denial of the noncertified days billed or the level of care provided. These denials require appeals, which result in a significant delay in account balance resolution, as well as an increase in staff resources needed to resolve an account.

For more information, see The Denials Management Training Handbook.

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