Collection Tip – Received an Authorization and Not Getting Paid?

Your patient is insured by one of the Health Maintenance Organizations. Your well-trained staff has followed the HMO’s protocol and obtained an authorization for a procedure or for services in the appropriate manner. You rely on that authorization number provided by the HMO, treat the patient, and then send in the claim with the authorization number clearly entered in Box 23 or Box 63 on the correct form. The claim is submitted timely to the correct payor and forwarded to the right address. Every step in the process has been perfectly executed. The claim is processed by the HMO and then returned to you denied – WHAT?

Don’t give up hope – appeal the denied claim and cite Florida Statute §641.3156. Basically it provides that a claim MAY NOT be denied if a hospital, physician, or other institution follows the HMO’s current and communicated authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the HMO with the willful intention to misinform the HMO.

Caveat: The patient must be eligible for coverage with the payor at the time the authorization was obtained.