In healthcare, a doctor’s priority is to provide the best care for a patient. However, this can sometimes mean deviating from our industry’s processes and regulations. One such process is pre-certification, also known as prior authorization, which may be required by the patient’s health plan.
While pre-certification is important to ensuring appropriate medical care, it’s vital to understand that it does not automatically guarantee payment. The true test comes when claims are submitted to the payer, such as a Third Party Administrator (TPA), which is reviewed against the Plan Document (the Plan).
There have been cases where healthcare providers have recommended (often encouraged) patients to visit the emergency room for non-emergency procedures. Although this may expedite the process, it often results in significantly higher costs compared to planned procedures and the potential of non-payment per the Plan as the services rendered were non-emergency in nature.
For example, consider an emergency room scenario where a provider received pre-certification for an emergency weight loss surgery. However, upon claim review, it was determined that the surgery was not deemed appropriate or medically necessary according to the Plan Document.
It’s essential to recognize that pre-certification is typically based on limited documentation, especially when conducted in emergency situations. Therefore, it’s imperative to review claims meticulously against the guidelines and limitations outlined in the Plan Document.
As the Plan holds fiduciary responsibility, ensuring claims are paid in accordance with the Plan Document is paramount. At USBenefits, we stand ready to support TPAs in conducting thorough reviews of high-dollar claims. Your goal is our goal – to provide the best possible outcome for the employer.
