In the health plan world, it is very important for both health professionals and patients to understand the words “prior authorization” and “pre-certification”. These words are used as synonyms most of the time but they indicate different procedures within the health system. The requirements are really difficult to navigate but a little knowledge of the difference will save patients time, frustration, and unnecessary medical expenses. This article sets forth the major differences between prior authorization and receptionist prior authorization by defining them and describing their purposes while focusing on how they impact patients and healthcare providers.
Prior authorization is essentially a demand by health insurers to approve certain medical services, procedures, or medications before they are actually provided. This allows the payer to determine whether the treatment or service is appropriate, medically necessary, cost-effective, and covered under the patient’s health plan. The payer may require prior authorization for hospitalizations, surgeries, imaging studies, high-cost or brand-name medications and special therapies.
It starts as soon as the healthcare provider sends a request to the insurance company for approval. This will most likely include detailed medical information such as diagnoses, treatments to be undertaken, and pertinent medical history. If the insurance company deems the service necessary and proper, it will approve the prior authorization whereby the provider can now undertake the treatment.
It relates to patients because if the insurance carrier does not approve it, then they might not cover the treatment or service. Consequently, the patient will have to pay out of pocket. Therefore, it is also important in terms of ensuring that patients get necessary medical care while controlling costs and avoiding unnecessary or inappropriate treatments.
What is Pre-Certification?
Pre-certification is just like prior authorization. It is the process whereby an insurance company reviews a medical service or procedure before it is performed. To this end, the term ‘pre-certification’ is typically applied to certain procedures and services about which the insurance company must certify the needfulness and appropriateness in regard to the patient’s condition.
Typically, this applies to medical services wherein elective surgeries, hospital admissions, or certain imaging procedures are laid. The insurance company reviews the medical necessity of the service according to information supplied by the healthcare provider and which details patient history, diagnosis, and proposed treatment.
The purpose of pre-certification is to make certain that the provider complies with the guidelines related to the requested service and that it accords with the patient’s health plan policy. In other words, it is a kind of upfront approval which seeks to weed out unnecessary costs by making sure that non-essential services are not provided. Once the insurance company approves the request, they share with the provider permission to go on with the procedure or service.
Key Differences Between Prior Authorization and Pre-Certification
The major differences between prior authorization and pre-certification are that they occur under different circumstances, the types of medical services for which one or the other is required, and how insurance companies handle the processes.
1. Terminologies and Application
This is the first major difference in terminology. The more popular one used across the board by most insurance companies and healthcare providers is “prior authorization,” while “pre-certification” tends to be more specific to certain types of procedures or services. It is elective surgery or hospital admission that requires pre-certification, and treatments—medications, imaging tests, and even durable medical equipment—may require prior authorization.
The list of services for which prior authorization is obtained is normally wider and includes prescription drugs, medical treatments, surgeries, and diagnostic tests. It is the process through which approval for any healthcare service perceived as unnecessary or costly is obtained. On the other hand, pre-certification usually applies to more specific situations — elective surgeries, inpatient admissions, certain medical imaging — and thus its scope is narrower than that of prior authorization.
3. When the Approval Process Happens
The usual snake of prior authorization is to seek approval before the services have been rendered. The timeline varies by type of service, how urgent the request is, and the policies of the insurance company. It might also be necessary to obtain pre-certification before a procedure for other things, such as verifying that an action aligns with the patient’s medical needs and the guidelines in an insurance policy. Therefore, it sometimes takes longer to secure a pre-certification than it does a prior authorization because additional documentation or even medical records may be required.
Medical Documentation Requirements
Both prior authorization and pre-certification require the provider to submit documentation to support the medical necessity of the service requested; however, they may vary in the type of documents and information required. Prior authorization is typically accompanied by detailed information on a patient’s medical history, diagnoses, previous treatments, and proposed treatment plan because it helps the insurer determine whether to pay for the services according to its policies and they are cost-effective. While pre-certification requires clinical justification for the proposed procedure, other aspects make it comparatively more thorough. For example, an elective surgery case would have to be proved as such a medical necessity by the insurance company that it was not purely cosmetic or elective.
Effects on Patients
This will thus have varied impacts on patients. Whether prior authorization or pre-certification, the approval process creates a situation where most patients will face delays in receiving the needed care. The damage that prior authorization inflicts on patients is less complicated than pre-certification because it usually entails less documentation. More importantly, when services are denied, patients can also feel terrible, especially if such treatment is urgent. From either process, therefore, denials can lead to out-of-pocket expenses for the patients if they pay for services not covered by insurance. This thus makes it necessary for patients to ensure that their healthcare providers know all about the authorization and certification processes required by their insurer.
Different Policies Among Insurance Companies
Not all insurance companies adopt the same policies or terminologies concerning prior authorization and pre-certification. Certain insurers may apply these terms synonymously whereas others differentiate more explicitly guidelines for each. That requires an understanding by both patients and healthcare providers of specific requirements of the insurance company they are dealing with. There may be instances whereby an insurance company will require prior authorization and also require pre-certification of services. For instance, a patient can have an insurance company that requires prior authorization for a medication and also requires pre-certification for an elective surgery related to the same condition. Therefore, it makes the process in healthcare more complex requiring additional coordination between patients, providers, and insurers.
Conclusion
“Prior authorization” and “pre-certification” are terms that people throw around interchangeably even though they denote different processes within health insurance systems. Prior authorization covers an expansive array of medical services—medications, treatments, and diagnostic tests. Pre-certification is more the domain of elective surgeries and hospital admissions.
Knowing the difference between prior authorization and pre-certification helps patients and healthcare providers work better with insurance so that needed services get approved and paid for. Both must be eager to learn the rules of the insurance company, supply all needed papers, and fix any problems that come up during the time for approval.
The ultimate goal of both prior authorization and pre-certification is to have patients receive the right care at the right time while managing healthcare costs and ensuring that the services are medically necessary. The process may be a bit daunting, but knowing what to expect and staying informed will help achieve a smoother healthcare experience.
Image by Andrea Piacquadio from Pexels
The editorial staff of Medical News Bulletin had no role in the preparation of this post. The views and opinions expressed in this post are those of the advertiser and do not reflect those of Medical News Bulletin. Medical News Bulletin does not accept liability for any loss or damages caused by the use of any products or services, nor do we endorse any products, services, or links in our Sponsored Articles.
In the health plan world, it is very important for both health professionals and patients to understand the words “prior authorization” and “pre-certification”. These words are used as synonyms most of the time but they indicate different procedures within the health system. The requirements are really difficult to navigate but a little knowledge of the difference will save patients time, frustration, and unnecessary medical expenses. This article sets forth the major differences between prior authorization and receptionist prior authorization by defining them and describing their purposes while focusing on how they impact patients and healthcare providers. Prior authorization is essentially a demand by health insurers to approve certain medical services, procedures, or medications before they are actually provided. This allows the payer to determine whether the treatment or service is appropriate, medically necessary, cost-effective, and covered under the patient’s health plan. The payer may require prior authorization for hospitalizations, surgeries, imaging studies, high-cost or brand-name medications and special therapies. It starts as soon as the healthcare provider sends a request to the insurance company for approval. This will most likely include detailed medical information such as diagnoses, treatments to be undertaken, and pertinent medical history. If the insurance company deems the service necessary and proper, it will approve the prior authorization whereby the provider can now undertake the treatment. It relates to patients because if the insurance carrier does not approve it, then they might not cover the treatment or service. Consequently, the patient will have to pay out of pocket. Therefore, it is also important in terms of ensuring that patients get necessary medical care while controlling costs and avoiding unnecessary or inappropriate treatments. What is Pre-Certification? Pre-certification is just like prior authorization. It is the process whereby an insurance company reviews a medical service or procedure before it is performed. To this end, the term ‘pre-certification’ is typically applied to certain procedures and services about which the insurance company must certify the needfulness and appropriateness in regard to the patient’s condition. Typically, this applies to medical services wherein elective surgeries, hospital admissions, or certain imaging procedures are laid. The insurance company reviews the medical necessity of the service according to information supplied by the healthcare provider and which details patient history, diagnosis, and proposed treatment. The purpose of pre-certification is to make certain that the provider complies with the guidelines related to the requested service and that it accords with the patient’s health plan policy. In other words, it is a kind of upfront approval which seeks to weed out unnecessary costs by making sure that non-essential services are not provided. Once the insurance company approves the request, they share with the provider permission to go on with the procedure or service. Key Differences Between Prior Authorization and Pre-Certification The major differences between prior authorization and pre-certification are that they occur under different circumstances, the types of medical services for which one or the other is required, and how insurance companies handle the processes. 1. Terminologies and Application This is the first major difference in terminology. The more popular one used across the board by most insurance companies and healthcare providers is “prior authorization,” while “pre-certification” tends to be more specific to certain types of procedures or services. It is elective surgery or hospital admission that requires pre-certification, and treatments—medications, imaging tests, and even durable medical equipment—may require prior authorization. The list of services for which prior authorization is obtained is normally wider and includes prescription drugs, medical treatments, surgeries, and diagnostic tests. It is the process through which approval for any healthcare service perceived as unnecessary or costly is obtained. On the other hand, pre-certification usually applies to more specific situations — elective surgeries, inpatient admissions, certain medical imaging — and thus its scope is narrower than that of prior authorization. 3. When the Approval Process Happens The usual snake of prior authorization is to seek approval before the services have been rendered. The timeline varies by type of service, how urgent the request is, and the policies of the insurance company. It might also be necessary to obtain pre-certification before a procedure for other things, such as verifying that an action aligns with the patient’s medical needs and the guidelines in an insurance policy. Therefore, it sometimes takes longer to secure a pre-certification than it does a prior authorization because additional documentation or even medical records may be required. Medical Documentation Requirements Both prior authorization and pre-certification require the provider to submit documentation to support the medical necessity of the service requested; however, they may vary in the type of documents and information required. Prior authorization is typically accompanied by detailed information on a patient’s medical history, diagnoses, previous treatments, and proposed treatment plan because it helps the insurer determine whether to pay for the services according to its policies and they are cost-effective. While pre-certification requires clinical justification for the proposed procedure, other aspects make it comparatively more thorough. For example, an elective surgery case would have to be proved as such a medical necessity by the insurance company that it was not purely cosmetic or elective. Effects on Patients This will thus have varied impacts on patients. Whether prior authorization or pre-certification, the approval process creates a situation where most patients will face delays in receiving the needed care. The damage that prior authorization inflicts on patients is less complicated than pre-certification because it usually entails less documentation. More importantly, when services are denied, patients can also feel terrible, especially if such treatment is urgent. From either process, therefore, denials can lead to out-of-pocket expenses for the patients if they pay for services not covered by insurance. This thus makes it necessary for patients to ensure that their healthcare providers know all about the authorization and certification processes required by their insurer. Different Policies Among Insurance Companies Not all insurance companies adopt the same policies or terminologies concerning prior authorization and pre-certification. Certain insurers may apply these terms synonymously whereas others differentiate more explicitly guidelines for each. That requires an understanding by both patients and healthcare providers of specific requirements of the insurance company they are dealing with. There may be instances whereby an insurance company will require prior authorization and also require pre-certification of services. For instance, a patient can have an insurance company that requires prior authorization for a medication and also requires pre-certification for an elective surgery related to the same condition. Therefore, it makes the process in healthcare more complex requiring additional coordination between patients, providers, and insurers. Conclusion “Prior authorization” and “pre-certification” are terms that people throw around interchangeably even though they denote different processes within health insurance systems. Prior authorization covers an expansive array of medical services—medications, treatments, and diagnostic tests. Pre-certification is more the domain of elective surgeries and hospital admissions. Knowing the difference between prior authorization and pre-certification helps patients and healthcare providers work better with insurance so that needed services get approved and paid for. Both must be eager to learn the rules of the insurance company, supply all needed papers, and fix any problems that come up during the time for approval. The ultimate goal of both prior authorization and pre-certification is to have patients receive the right care at the right time while managing healthcare costs and ensuring that the services are medically necessary. The process may be a bit daunting, but knowing what to expect and staying informed will help achieve a smoother healthcare experience. Image by Andrea Piacquadio from Pexels The editorial staff of Medical News Bulletin had no role in the preparation of this post. The views and opinions expressed in this post are those of the advertiser and do not reflect those of Medical News Bulletin. Medical News Bulletin does not accept liability for any loss or damages caused by the use of any products or services, nor do we endorse any products, services, or links in our Sponsored Articles.
