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Case Studies > Retroactive Authorization
Authorization denial reversed by reaching out to payor’s Provider Representative
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Key Takeaways
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Two regular patient treatments occurred during a brief lapse in authorized service dates and were denied for no authorization
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Titan auditor asked payor's Provider Representative to advocate on behalf of the contracted facility and get the authorization updated
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Provider Representative was successful in getting the payor to issue a retroactive authorization and overturn the previous denials
Overview
A patient in a 5-hospital system in Arizona had been receiving authorized and covered infusion therapy for months. Although multiple authorizations had been issued by the payor during the patient’s course of care, two treatments occurred during a brief lapse in authorized service dates and were denied for no authorization.
The Challenge
Titan auditors initially followed the payor’s documented reconsideration and appeals process and attempted to obtain retroactive authorization for the denied dates of service. The payor repeatedly refused to issue the additional authorization and the claim denial was upheld.
The Solution
Titan Health ultimately escalated the issue by reaching out to the payor’s Provider Representative. We explained to the representative that the payor had clearly established the treatment as a covered service, paying for the costly infusions both prior to and after the denied service dates. Medical necessity wasn’t the issue; an authorization had simply and mistakenly lapsed. In the spirit of compromise and to preserve an amicable working relationship, the auditor asked the representative to advocate on behalf of the contracted facility and get the authorization updated.
The Results
The Provider Representative was successful in getting the payor to issue a retroactive authorization and overturn the previous denials. This resulted in the hospital collecting $173K for the two previously denied dates of service.