Quality Assurance

It’s important that we get it right the first time.

By Linda Nguyen, Funding Manager

Did you know, National Seating & Mobility holds the risk when payer(s) do not provide prior authorization? Our highest risk orders are those where we do not have a prior authorization from a payer and those where we have received an invalid denial. We can help reduce this risk and ensure not one bad dollar!
Any requests that are not reviewable for pre-cert or pre-determination, it is important that we contact the payer to determine if the service is a covered benefit. If it is, we must ensure insurance coverage criteria is followed, and that medical documentation is thoroughly reviewed before marking the payer as submitted and approved. Furthermore, it is essential to validate the denial(s) as secondary payers require specific primary denial codes and reasons before they will pay on a claim.
The final opportunity to ensure the work order is funded compliantly before purchasing the equipment is at the time of PPQA – Pre-Purchase Quality Assurance. The following steps should be taken at PPQA to ensure the client doesn’t receive any unwelcome surprises (hello copayment!) and that we have all that is necessary to secure a claim payment for all of the hard work we’ve done.

Re-verify eligibility and benefits for all payers ensuring a copy of the benefits is scanned into the work order. Include all pages for commercial payers to ensure we’re validating co-pays, deductible, OOP and DME Max benefit information. If we can’t get that online, we must call the payer to obtain it.
Review all scanned documents to ensure that they are valid and have not expired.
Review all authorizations and denials for accuracy and expiration dates.
Review the summary tab to ensure that the order is booked properly.
Contact client to share an update on the status of their order and discuss and collect any final amounts due.

Proper execution of each step during the PPQA will alleviate unnecessary delivery delays, help ensure we are effectively communicating with our clients and reduce payment risk. This is one of the many ways we can provide great service to our clients.