Prior-authorization/Pre-certification

Pre-certification, also known as prior-authorization, occurs before care is rendered. In this process, reviewers evaluate a patient’s specific medical situation to determine whether the healthcare service the provider recommended will be eligible for coverage. Pre-certification does not always guarantee payment; however, it does ensure that the provider will be reimbursed for the service once the provider verifies that the care in question was actually provided.

Generally, payers will require providers to obtain pre-certification for procedures that have high-dollar reimbursement, have the potential to be used inappropriately before lesser and more conservative treatments have been attempted, or have complex indications usually subject to pre-certification requirements. Pre-certification is also routinely required for elective inpatient admission to a hospital.

This process has multiple advantages, including:

  • Preventing inappropriate care;
  • Directing  care to a more appropriate and less costly setting;
  • Educating providers on best practices to inform their future decisions and requests; and,
  • Occurring before payment is made.