Jack Smith is back again. This time for a cardiology visit. Doc ordered an echocardiogram (CPT 93306). UHC Medicare Advantage plan in hand, he sat in the waiting room flipping through a 2018 issue of *Better Homes & Gardens,* blissfully unaware that behind the front desk, Jill was staring at her monitor like it had just personally offended her.
See, Jill wasn’t told what Jack was here for. Holly, the practice admin (you remember her: clipboard, four acronyms after her name, none of which help anyone), forgot to mention it during her morning power strut into the front desk area. Jill, underpaid and overstimulated, just checked him in and sent him back like always.
Now here comes Chad the Auth Guy™.
He works in his own little corner of man cave. Eight tabs open. None of them is the actual UHC portal. Sips coffee like it is a performance. He has a spreadsheet Holly gave him of patients coming in this week for an echo test, and Chad’s job is to check the insurance plans for each of those patients to see which ones require obtaining a prior authorization for the CPT code 93306 and to start getting that procedure approved for services.
Quick refresher: A prior authorization is pre-approval from the insurance company that says, “Yes, we agree to pay for this test, but only if you ask first.” That means someone like Chad is supposed to check each patient’s insurance, confirm whether 93306 needs a prior authorization, and then submit the request before the patient shows up. If no one does that? The test still happens, but the payment for the service will never happens.
And no, this is not 1985. Getting a prior auth is not about sitting on hold for an hour with smooth jazz playing. Most payers have online portals where you log in, select the CPT code, attach the chart note, and submit. The whole thing takes maybe ten minutes. Unless you’re Chad, who still thinks faxing is cutting-edge.
Sasha says it best: “Your clinic isn’t broke because billing messed up. It’s broke because you’re still operating like it’s 1985 with a fax machine and a dot matrix printer.”
So, going back to Chad, what did he do?
He did nothing.
Sasha, our resident billing queen, spots the problem when she reviews the visit in the EHR post-appointment section. She sees the CPT code 93306. She sees Jack’s name. She sees no prior auth approval number. Her heart rate spikes, not because she is worried, but because she already knows how this will go down.
She informs Holly, “This claim is going to be denied. No prior auth.” and Holly says bill it anyway and appeal later.
A week later, UHC denies the claim faster than you can say “Holly’s management style is a red flag.” Sasha shows the denial reason. Holly shrugs and says, “Send medical records as an appeal.”
Sasha holds back a laugh. No amount of medical records is going to get that claim paid. UHC is not issuing a retroactive prior authorization. Explaining that the test was medically necessary is not going to make any difference. They will still deny it.
Now, here comes the Doc storming into the billing office. “Why is my AR so high? Why aren’t these denied echoes being appealed? Send them medical records, we will prove it was medically necessary!”
Sasha just stares. There are no retro-authorizations. No appeals, no medical records, no magical thinking that will force UHC to pay on these claims.
And you know who gets blamed? Jill and Sasha.
Not Chad the Auth Guy™.
Not Holly, who signed off on the claim to get submitted without prior auth.
Not Doc, who thinks every insurance company operates on his ego.
Sasha is now supposed to perform billing CPR on a flatlined claim that United Hell (yes, them) gleefully rejected without flinching.
Holly ends up billing the $800+ claim to the patient, knowing it’s wrong, and knowing she will eventually have to write it off when the patient refuses to pay.
Sasha does not say a word. Yet her expression says, “Try me. I dare you.”
And Chad? Chad is still sipping coffee, asking if this week’s spreadsheet is updated.
Meanwhile, Jack’s sitting at home holding a bill from the cardiology office, confused why his ‘routine’ test got denied by UHC, and why he got the bill from the cardiology office.
And no, Jack is not responsible.
Jack came in for an echocardiogram, not an economics lesson on how broken your medical practice is.
Welcome to the real reason your revenue is bleeding. And no, it is not the billing department.
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