Pre-Certification of Treatment by Health Insurance Company

In our sample individual health insurance policy there is a requirement that certain medical treatment be pre-certified by the insurance company in advance of treatment. If this requirement is not met, there is a deductible that you are required to pay. In our sample policy the deductible is $1,000.

This is yet another example of how the insurance company tries to limit its exposure – not so much by tacking on another $1,000 you have to pay, but, more importantly, by using the threat of this deductible to encourage you to pre-certify. The pre-certification process gives the insurance company the opportunity to control the costs, costs that may be considerably greater than $1,000. You will see how this works as we review the following sample pre-certification provision.

(Typical wording*): Pre-Certification of Treatment If an Insured notifies and obtains from Us a certification that Covered Expenses are to be incurred due to a Medically Necessary Hospital Confinement or Outpatient surgery, We will pay the applicable benefits for the Covered Expenses of services rendered as specified under the terms and provisions of this Policy and any riders, amendments or endorsements attached hereto. Certification must be obtained prior to all Inpatient admissions, except in the case of an Emergency admission. In the event of an Emergency Inpatient admission, the Insured or his or her Provider must notify Us within seventy-two (72) hours of Confinement, or as soon thereafter as reasonably possible.

 

“Pre-Certification of Treatment” is the process whereby you, the insured individual, obtain prior verbal or written authorization from the insurance company for medically necessary hospital confinement or outpatient surgery.It is not required in advance for emergency inpatient admission. However, post-admission certification is required within 72 hours of admission or as soon thereafter as reasonably possible.

(Typical wording*): At the time notification of surgery is made, We will inform the Insured and his or her Provider if a second opinion is required, at the expense of the Company, before certification will be given and will assign a length of stay if it is determined that Inpatient hospital care is Medically Necessary. We may extend the length of stay upon the request of the insured or the Provider if We determine an extension is Medically Necessary. No benefits will be Provided under this Policy for expenses that are determined not to be Medically Necessary. Treatment Provided at any time after initial certification that differs from the specific plan of care and treatment previously authorized requires re-certification by Us.

 

Pre-Certification of Treatment, services and/or length of stay is not a guarantee of coverage under this Policy. All claims for benefits under this Policy, including claims for services and treatment that were pre-certified by Us, are subject to all terms, definitions, limitations, exclusions and restrictions contained in this Policy and in any riders, endorsements or amendments attached hereto.

As you can see, the primary purpose of this provision is not to cause you to have to pay another $1,000 in deductible expenses. The primary purpose is to cause you to have your plan of care reviewed by the insurance company in an attempt to reduce the likelihood of medically unnecessary expense being incurred that would, after the fact, not be covered by the company, much to the dismay of you, the insured individual.

No benefits are payable under the policy for any covered expenses that are subject to this failure to pre-certify treatment deductible until after the amount of the deductible is satisfied.

Note that if your hospital stay needs to be extended or your plan of care needs to be changed, you need to get these changes certified by the company or the deductible may be applied.

*Wording may vary from contract to contract and from state to state.

Case Studies: Pre-Certification of Treatment by Health Insurance Company

Case Study 1: John’s Experience With Pre-Certification

John, an insured individual, faced the pre-certification requirement when seeking medically necessary hospital confinement. This case study explores how John navigated the process and highlights the insurance company’s control over costs and coverage decisions. Despite initial challenges, John learned the importance of pre-certification for maximizing benefits under his policy.

Case Study 2: Sarah’s Journey through Pre-Certification

Sarah’s case sheds light on the primary purpose of pre-certification. As she prepared for outpatient surgery, Sarah sought approval from her insurance company to ensure coverage. This study showcases how the insurance company’s review helped Sarah avoid potential out-of-pocket expenses and underscores the significance of complying with pre-certification requirements.

Case Study 3: Mark’s Lesson on Recertification

In this case study, Mark’s hospital stay extended beyond the initially authorized period, highlighting the importance of recertification. Mark’s experience demonstrates the potential consequences of not obtaining recertification promptly. By understanding the process and promptly communicating changes in his plan of care, Mark successfully avoided additional costs.