If you’re like most Americans, the topic of health insurance is probably confusing to you. Over the years, it has evolved into a complicated mess of paperwork, regulations, restrictions and medical jargon terms that leave most people scratching their heads. What is even more frustrating than reading your policy is trying to get the care you need when you need it. This is especially true with HMOs. If you have had any non-emergency surgeries or medical procedures in the recent past, you probably are familiar with pre-certification procedures or pre-certs.
What Is Pre-Certification?
Pre-certification is aprocedure where your insurance company authorizes a specific medical procedure you need. For example, if you injured your ankle years ago and are now having problems with it, your insurance company may require you to go through pre-certification procedures before you can have a surgery that is needed to help you regain full use of it without pain. A physician would examine your ankle, decide what tests are necessary and then your insurer would make a decision based on what the doctor recommends.
What are the problems with Pre-Cetification
When you initially signed up for a health plan, you probably read over what is covered and what is not. It is likely you made your decision based mostly on what you read. What an insurer covers and how much the deductible is are two very important considerations when you enroll in a health plan. However, both of these pose serious problems when it comes to pre-certification, and many people are not aware of the pre-certification rules and how they affect what is actually covered and to what extent.
First of all, pre-certification takes time. During the time between your initial doctor visit when it is determined you need care and when the insurer approves the procedure, several months may pass. If you have an illness or condition that constantly worsens without treatment, you could end up spending much more for complications than you would spend on the surgery.
If you picked a health plan because it seemed to have good coverage for orthopedic treatments and surgery, you might have assumed that all treatments and surgeries are covered exactly to the extent they say in the policy. However, there are often large deductibles you must pay if you have these surgeries without pre-certification from your insurer. The surgery or treatment will still be covered as it says in the policy but only if the insurer authorizes it. Otherwise, you can elect to have the procedure performed, but you will have to pay for that huge deductible out of pocket and any other expenses defined by your policy.
Why Does Pre-Certification Exist?
Pre-certification exists for several reasons. Insurers say the main reason is so they can determine if the care you need is medically necessary. By doing this, they claim they are able to cut down on their costs. For example, say you are in good health and are 25 years old. If you have a plan that covers CT scans and you want to have one just to make sure you are in good health, your insurance company may argue that you lack the medical history to warrant one. So, they would see this as an unnecessary expense. They argue that by weeding out such expenses, they are able to lower the cost of premiums to consumers as well.
Another reason there is so much red tape and so many pre-certification requirements in place to receive care is because of lawsuits. With so many lawsuits constantly going through the system, it is being slowed down heavily. To address these various issues, insurers have added more checks and balances in hopes of evening out the problems. While it may help solve some of the problems on their end, it certainly is not helping people who are waiting for the care they need. For example, a cancer patient who needs to have surgery may benefit the most from having it done immediately. The longer this person has to wait to gain approval for the surgery, the more he or she is at risk of a the cancer spreading if it is metastatic. A person does not even have to be sick in the first place for these requirements to have a negative effect. Some people may get sick while waiting for a preventative test or treatment.
What Procedures Require Pre-Certification?
This is something that will vary from one insurance company to the next. However, most insurers do require pre-certification for non-emergency surgeries and treatments. They may also require pre-certification for some emergency procedures, which can put patients in jeopardy in many cases. MRIs, CT scans, inpatient hospice care and non-emergency surgeries are some common examples of procedures and treatments that come with pre-certification requirements.
What Happens If I Don’t Pre-Certify?
If you do not meet the requirements your insurer has outlined, you will be stuck paying a large deductible. This is named in your insurance policy, so it is important to be aware of it. Some people choose policies that have lower deductibles but higher premiums, and others choose policies that have higher deductibles and lower premiums or more comprehensive plans. There is no right or wrong choice in this matter. As a rule, healthier people tend to pick higher deductibles and people with ongoing health issues usually pick lower deductibles. Even if you are not admitted for a non-emergency procedure, you could wind up paying your deductible.
If you had to be taken to the emergency room, sedated and underwent surgery, you obviously would be unable to contact your insurer to gain their approval. In some cases, your surgery may be covered depending on the surrounding factors. However, it may not be covered if these factors do not meet the insurer’s requirements. If you try to go into a hospital or other medical facility for a treatment that isn’t covered, you could also end up sitting and waiting for a long time for your insurance company to approve it. This happens often, and these long waits can cause scheduling lags and make everyone have to wait longer. For those who need prompt or emergency care, this is a serious issue.
Many people debate whether pre-certification is helpful or harmful. The bottom line is that it may be helpful to insurance companies and it may contribute a small bit toward slightly lower premiums across the board, but the cost it has on the majority of people who must wait for it is a negative thing. Pre-certification is definitely frustrating to think about and even more so to deal with, but it is in your best interest to be aware of what procedures your insurer has to pre-certify care and what you can do to make the process easier. Here are a few helpful tips:
Tip #1. Research sites such as guideline.gov and icsi.org to learn about evidence-based guidelines for your condition.
Tip #2. Ask your insurer for specifics about pre-certification guidelines. Some will provide this information, and Medicare has this information on their site under the coverage database.
Tip #3. Make sure you include documentation of your health condition. Write legibly when you submit your forms, and make sure the information is complete. If you feel your insurer is asking for too much, it is best to provide the information anyway but submit a complaint about it. If you don’t include the information, it could complicate matters.
Tip #4. If your insurer does not respond in a timely manner, follow up with them. For non-urgent requests, approval or denial should come within 15 calendar days. If it doesn’t, contact the National Committee for Quality Assurance.
Learn other ways to protect your health by visiting www.georgeflinncares.com.