Top 5: Ways to Control the Cost of Healthcare #5

5. Get pre-authorizations or predeterminations of

benefits done when necessary

Pre-authorizations are prior approval from an insurance carrier for a procedure. These are not guarantees that the claim that comes in will be covered, but it is a statement that the insurer intends to cover the service. Many non-emergency medical procedures and services require a pre-authorization, and it is important to ask your physician if a prior-authorization is needed before a procedure. Most physicians will be generally aware of procedures requiring a pre-authorization, and they will call into the insurance carrier for review. Without a pre-authorization, some claims that might have been covered will be denied. If you want to be certain that a procedure does or does not require a pre-authorization, you can always get the procedure coding from your provider and call them in to your insurance carrier to verify.

Predeterminations of benefits are similar to pre-authorizations, but they are not required. Often, they are done for procedures in which a provider must prove that a patient meets medical criteria for a procedure before it can be performed. For instance, treatment of varicose veins is often denied as not medically necessary. However, if a physician does a predetermination of benefits with the insurance carrier and can provide documentation proving that the member meets the medical criteria, the procedure could be covered.

While it is always important to consider your health and the advice of your physician first, you can also help to control the cost of your healthcare by ensuring that the necessary steps (such as getting a pre-authorization or predetermination of benefits) are taken before any major procedure.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.