Question

Goal: Display tactful behavior when communicating with providers when communicating with medical providers regarding third party requirements. Show sensitivity when communicating with patients regarding third party requirements.

Materials: Prior authorization form, patient medical chart with planned procedure and CPT code. Diagnosis for proof of medical necessity.

Scenario: Patients preauthorization was denied because a second opinion is required. You must explain to the provider new policies from the insurance company requires a second opinion before they will approve the procedure. You will explain to the patient the new policy of their insurance carrier requiring a second opinion for corroboration of medical necessity before the procedure will be approved.

1. Tactfully explain to the providers the insurance carrier’s new policy requiring a corroborating second opinion prior to approval for the procedure.

2. Demonstrate sensitivity explaining to the patient the necessity of a second opinion to corroborate the medical necessity of the procedure prior to approval

Answer 1

1) The providers has to be explained in brief

* The type of disease condition

* How it will be treated

*Duration

*Benefits

*Risk factors

* Any major complication which may result out of the procedure performed.

It is always best to provide the provider with full information and corroboration for a second opinion should over rate the current scenario and the necessity to avoid problems for both parties.

2) The patients are the one who totally believe on the health care professionals when undergoing any procedure.

It doesn't means misusing the rights , making patients fearful and getting appointment with out their knowledge

So it the duty of the health care professionals to tell them the need of second opinion and it's benefits in a condition and environment best comfortable for them.