Out of Network Waivers Flashcards
What is a Step Process?
* Insurance verification information
* CPT codes assigned to the imaging study
* Layers of testing that must be done before others
* The total distance between the patient’s home and in-network facility
Layers of testing that must be done before others
If a potential error is made by the insurance company, what can the authorizer do to correct this situation?
* Submit an out-of-network request
* Submit an in-network request
* Call the insurance company and make a strong case for the patient
* Explain the situation to the patient
Call the insurance company and make a strong case for the patient
TRUE/FALSE It is the responsibility of the authorizer to know how reduced circumstances will affect the payment of claims.
* FALSE
* TRUE
True
The goal of the authorization is to receive approval from the insurance company. To gain that approval, the authorizer needs to:
* Prove that the request meets the insurance company’s guidelines
* Ask the provider to give treatment information
* Not include the insurance company in the medical records submission
* Require the patient to navigate the insurance company’s websites
Prove that the request meets the insurance company’s guidelines
Mr Virgil has prostate cancer. His insurance company wants him to utilize a radiology clinic near his home that specializes in breast cancer, not prostate cancer. Even though this physician is trained in both breast cancer and prostate cancer radiation Mr. Virgil states he would prefer to use a different physician. When reaching out to the insurance company, what is the best course of action? Select all that apply
* tell the insurance company how stupid they are for not acknowledging the differences between a breast and a prostate
* make a strong case for Mr. Virgil, stressing his particular needs
* don’t call the insurance company at all since you now know this radiologist is trained in both prostate cancer and breast cancer treatment
* make sure the insurance company acknowledges that even though the radiologist is trained in prostate cancer the clinic does not regularly practice this type of radiology and is not equipped to deal with this type of treatment
make a strong case for Mr. Virgil, stressing his particular needs AND make sure the insurance company acknowledges that even though the radiologist is trained in prostate cancer the clinic does not regularly practice this type of radiology and is not equipped to deal with this type of treatment
When can an Out-of-Network Waiver be approved?
* Treatment is only available at the requested site
* The distance at the provider site is less than 50 miles from the patient’s home
* The network provider is board-certified
* The network provider is experienced with the diagnosis
Treatment is only available at the requested site
Gayle is an 86-year-old woman living in a care facility in a rural area of Nebraska due to a broken hip. She is in need of a surgical procedure that can be provided at an outpatient surgery center her physician recommends which is about 20-minutes from her home. Unfortunately, since that center is out-of-network the insurance company is suggesting an alternative facility that is 50 minutes from her home. The physician would like to perform the surgery ASAP but since it is currently January in Nebraska, Gayle’s daughter is concerned about the road conditions that time of year. What are some reasons a network appeal might be successful for Gayle? Select all that apply
* Distance
* needs surgery soon
* physician recommendation
* winter roads
* mobility issues
All except physician recommendation
A waiver of network status is sometimes referred to as a:
* Gap Waiver
* Waiver Request
* Network Waiver
* Out-of-Network Request form
Gap waiver
If an out-of-network form is not available and the authorizer needs to write a letter, which of the following steps should be taken? Select all that apply.
* Research and document the need for an out-of-network waiver
* Create an out-of-network form
* Call the provider line to get a fax number or email address
* Write a letter that includes all the pertinent information
all except “create an out-of-network form”
What is a Network Status?
* Payment based on patient in-network cost
* Payment based on patient out-of-network cost
* Financial contract between the patient and insurance companies
* Financial contract between the insurer and the facility or the insurer and the physician
Financial contract between the insurer and the facility or the insurer and the physician
