Verifications

Here are some key items most verifications fail to include that result in avoidable denials:

• Eligibility – After you verify benefits call the employer to verify current eligibility. If your specialty requires you to maintain a patient’s confidentiality with respect to the type of treatment (e.g. CD or Mental Health), use the name and UPIN of the professional doing the H&P’s;
• Group Plans - determine if it is an HMO or PPO and who is doing the reviews for these.
  DON'T ALLOW STAFF TO ASSUME THAT A NATIONALLY KNOWN INSURANCE COMPANY ONLY HAS GROUP PLANS. THEY DON'T!!!
• Clearly delineate the type of Plan if not a Group:
• (1) Self-Funded Plans - determine if the managed care is an administrative organization (ASO). Get the name and contact number for the employer's HR staff (who should have been called for the eligibility verification).
• (2) Federal Government Plans - Ultimately recourse is legal action through OPM; time consuming and generally unproductive. ARA has had some success with alternate methods but be aware when you get these patients that your options are limited.
• Appeals – Ask how many internal appeals are available? Do these include the concurrent and expedited peer reviews? If yes, you may have no further internal appeal rights. After internal appeals are exhausted is there a next level of appeal to an IRO/ERO or to the Employer/Plan? Be sure to have this information available to UR/UM staff.
• Pre-existing - When applicable be sure to document and request a copy of the specific wording and time frames included. Some Pre-X are specific to diagnosis and treatment, while others are very general e.g. a condition which any reasonable person would determine existed...
• Preauthorization by Secondary Payers- Clarify the policy up front and ask for a copy of their policy and a written release from HIPAA compliance.