Do people on supplement plans still need prior authorization for surgery?

[sam816]

Granted the authorization is obtained from CMS directly not a private insurer, so the process is quicker?

TIA.

 

[somarco]

I have never heard of prior authorization being required for any procedure.

If it is medically necessary, it is paid. If not, it isn't.

The ABN form is your friend.

 

[WCMason]

Granted the authorization is obtained from CMS directly not a private insurer, so the process is quicker?

TIA.

Need for precert with Original Medicare is rare. One example is a beneficiary whose drooping eyelids are affecting vision. Surgical repair is considered plastic surgery, usually not covered, but in this case medically necessary.

 

[somarco]

Blepharoplasty

 

[bill3173]

It's rare that anyone would have a surgery done without knowing first whether it is medicare approved. I did have an instance recently where a lady had a procedure done, and called to tell me she had to pay the whole thing, and the supp didn't pay. I reminded her that the supp is tethered to medicare, so it must not have been approved.

After I said that, she told me that she went to an opt out doctor, which is even rarer, but she knew she was going to have to pay.

 

[goillini52]

Need for precert with Original Medicare is rare. One example is a beneficiary whose drooping eyelids are affecting vision. Surgical repair is considered plastic surgery, usually not covered, but in this case medically necessary.

I've also seen this covered by Medicare.

 

[somarco]

Doctors that regularly treat Medicare patients should know if a test or procedure is going to be covered. If in doubt, they SHOULD have the patient sign an ABN form.

Have a few clients that had this surgery. Approved by Medicare since it met the definition of medically necessary. Same process applies to U65 health insurance except in those cases pre-authorization is usually required. Won't be paid if strictly cosmetic surgery. Only if medically necessary

No ABN form, claim denied by Medicare, you don't owe it.

Signed ABN form, claim denied by Medicare, you owe it.