VA Profile -- Maria Elisa Suan II
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"I have been working as a Provider Service representative for Medicare and Retirement for more than five years. My job is to answer queries from healthcare providers about a member's eligibility and benefit details, creating auth requests, and assisting with claims processing. Typically, a caller will check if a member is eligible and then ask about Prior Authorization requirements before rendering the service. After that, they bill the claim.
Usually, our callers are case managers from hospitals and skilled nursing facilities requesting approval for an in-patient authorization. Ideally, CMs or case reviewers from the healthcare facilities and the insurance company have direct contact with each other but because of the multitude of cases in the work queue, communications are not consistently kept fluid. So we, in the frontline act as their intermediary to resolve issues that would arise in some cases. A lot of times, issues would be about medical records which were not successfully sent or not requested to begin with, and medical records that prove the non-medical necessity for further service thus creating problems with a patient's eligibility for continued stay at the hospital or lower level of care. I would use an internal messaging application like Outlook, MS teams, or Jabber to communicate with our CMs in these situations so that they can reach out to the hospital or SNF.
Prior authorization and claim denials are always queued up for appeal. I'd say one of the most common reasons for denials, besides the certain limitations in a member's benefit, is lack of medical records and my role as a representative is to help, in one way or another, avoid it by providing instructions on clinical submission upon case creation, verifying receipt of medical records after a claim has been billed and more importantly, communicate to whoever will be able to provide resolution."
