I am scheduled for surgery very soon. How do I know if anything related to my surgery needs precertification and/or approval?

I am scheduled for surgery very soon. How do I know if anything related to my surgery needs precertification and/or approval?
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#1

I am scheduled for surgery very soon. How do I know if anything related to my surgery needs precertification and/or approval?


#2

Lack of per-certification and approval is a major factor in denial of claims after they are submitted.  The policy holder is ultimately responsible for obtaining such approvals.  The easiest way to do this is first to call your insurance company to determine if you need such pre-certification.   You may need the specifi diagnosis and procedure codes which you can obtain from your doctor's office.   Many providers will tell you that they will obtain the precert fore yopu.   While this lets you off the hook for doing this activity, make certain it is accomplished by following up with your insurance comanpy. 


#3

Regardless of what a physician of his/her assistant may tell you regarding pre-certification, always check yourself and ask for that approval in writing from your insurance carrier.  Get the precise wording of your surgery from your physician's office and use it with the insurance company.  Make sure the facility where your surgery will be performed accepts your insurance, as well as your doctor, any medical assistant, the anesthesiologist, and labs conducting biopsies or related tests.   Pay close attention to details concerning your discharge, and ideally have your healthcare agent or patient advocate with you.  The first few days at home are crucial to establishing the foundation for a successful recovery.  Ideally you won't have to spend the first few nights home alone.  Also pay as much attention to your after-care being covered.  Physical therapy needed?  If so, get a written prescription from your doctor before leaving the hospital.  Line up the facility before as well.  Confirm they will accept your insurance, and for how many visits.  No detail is too small when coordinating successful surgery and recovery.  Good luck!


#4

Your surgeon should check on this before the surgery and do this for you.

You might want to contact your insurance company and check on their requirements.


#5

You should receive something from your insurance company prior to surgery stating that you are approved. If not you will want to call your insurance company to make sure everyone is covered and the pre-certification is in place.
Normally, the surgeon and the hospital will both get their approval for the surgery from your insurance company. Their failure to do so as an in-network provider they can not balance bill you if they do not receive payment.
If the provider is out of network and prior pre-certification is not received they can bill you later on.
So, verify with your insurance company that pre-certification is in place for your surgery.
If any portion of the surgery is applied to your deductible or co-insurance reach out to a medical bill advocate who can audit the medical records for correct coding, compliance, pricing and negotiate any out of pocket expenses!
Best of luck to you!
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates


#6

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