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When Medical Referrals or Authorizations are Missing When You are Ready to Bill

As a medical coder or biller, what do you do if the necessary referral or authorization wasn’t secured before the fact? You play nice. Somebody has to do the paperwork for referrals or prior authorizations, and that somebody is unlikely to be the physician.

So whose job is it? Everybody’s. The scheduler, the coder, and the biller should all know when a referral or prior authorization is needed. Of course, by the time the case reaches you, the biller/coder, the encounter has already taken place.

If you haven’t sent the claim yet, it may not be too late to call the payer and secure the necessary referral or authorization. Or you may be able to contact the primary care physician and explain the situation. Often she will issue the necessary number or form that allows the claim to be submitted within the provision of the patient’s plan.

If the need for referral or prior authorization goes unnoticed until after the claim has been denied, the job falls to the person responsible for accounts receivable follow up to try to get the retroactive authorization or referral. Sometimes you can obtain this by submitting an appeal along with the medical records to support medical necessity.

Getting hostile with the payer if the claim has been denied because your office didn’t do the necessary work up front doesn’t benefit anyone. Instead, explain that a miscommunication occurred and that you’re sorry for the confusion; then very nicely ask, “What can I do to straighten this out and get the claim paid?”

Afterward, to avoid a recurrence, use the denial as a teachable moment for other members of the staff. You also may want to post a list of known payers who require prior authorizations or referrals for services performed in your office.

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