The Benefit of Checking Benefits

by  Fabrienne Castro
Dec 11th, 2015

By: Donna Weinstock (Sep/03/2014) 

Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure?

In many cases outpatient procedures and surgeries do not require pre-authorization or precertification, but that does not guarantee payment by the insurance company. Insurance companies frequently require patients to meet criteria prior to having surgery. What is the difference between pre-authorization, pre-certification and pre-determination?

Pre-authorization is getting approval or permission for the procedure or surgery. Without the permission, the insurance company may not pay for the procedure. This may include learning the patient’s benefits or allowances for such procedures.

Often, physical therapy, occupational therapy and chiropractic services require approval prior to beginning of the services. An MRI or CT often requires approval from the insurance company. Without the prior approval when required, the insurance company won’t pay. As physicians staff members, it may be our responsibility to gain the approval.

Pre-certification is the gaining of approval from the insurance company by proving medical necessity. Often this is done by having the insurance company review documentation and medical records regarding the treatment to date of the patient. The goal here is for the provider to prove that the procedure is medically appropriate and needed. Insurance companies are looking to save money by requiring more conservative treatment prior to surgery.

Spinal and fusion surgeries are one of the procedures that insurance companies are looking to have patients do more conservative treatments prior to undergoing surgery. When a policy reads that the patient must undergo 6 months of physical therapy and a provider chooses to perform the surgery after 4 months of therapy, the insurance company most likely won’t pay for the surgery. Simply stated, the patient did not meet criteria. It does not matter how much pain the patient is in. Nor does it matter how many pain medications the patient takes during the day; the patient did not do what the insurance company required. Physician practices should fight on their patients’ behalf for the precertification when indicated whether or not the criterion has been met. They also need to be prepared to have some requests denied.

Who is left with the unpaid balance? More than likely the practice would not be paid. Most patients do not have the money to pay out of pocket for surgeries. We often forget that it is not only our bill that isn’t paid; the hospital, the anesthesiologist and all other bills will be denied by the insurance company.

Patients need to meet “medical necessity.” For most medical procedures, meeting medical necessity should be straightforward with proper conservative treatment and documentation provided the patients and providers follows the insurance guidelines and requirements. The most difficult (if not impossible) cases to prove medical necessity are for cosmetic surgeries.

For questionable coverage of a procedure or surgery, a practice may request a “predetermination of benefits” from the insurance company. What you are asking for is a written verification of the policy benefits and whether a specific procedure is covered by a patient’s insurance. Often this is done for procedures that may be considered experimental or not proven. A surgery does not need to be experimental for a carrier to label it as such. Knowing what is covered allows a patient to maximize their benefits and know up front what should or should not be covered.

Predetermination also allows the insurance company (most often by a physician) to review the patient’s records to determine whether the insurance carrier considers the requested procedure to be medically necessary.

Failure to do your due diligence prior to a procedure will often result in non-payment. Precertification, pre-authorization, predetermination and benefit verification will allow for better reimbursement of the procedure or reimbursement at all. Providers as well as patients need to be aware of their contractual agreements with the insurance carrier for the best opportunity for reimbursement.