Do I Need to Get Pre-Certification Before My Hospital Stay? Info on Health Insurance Coverage

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What are Pre-Certification Requirements?

Some health insurance companies have pre-certification requirements for coverage of some medical expenses. Insurers use precertification to control health care costs and limit unnecessary medical procedures.

Medical pre-certification is often required for hospital stays where a patient is admitted to a hospital. If a patient wants to have non-emergency surgery, he will need to contact his health insurer prior to his surgery. Insurers may require that a non-emergency procedure be pre-certified a specified number of days in advance of the procedure. Some health insurance companies want outpatient surgeries and other outpatient medical procedures to be pre-certified as well.

A patient may also need to have his doctor’s office contact his health insurance company in order to complete the pre-certification. Health insurance companies ask for medical procedure codes, medical diagnosis information, and expected charge amounts. Medical pre-certification is complete when the health insurer approves coverage for a planned medical procedure.

Insurers also like to get precertification for emergency hospital admissions. A patient may not be able to pre-certify before emergency surgeries or emergency in-patient care is given. Health insurance companies may require that they are contacted no later than forty eight or seventy two hours after hospital admission.

What Happens If I Don’t Pre-Certify?

If you don’t meet your insurance company’s precertification requirements, this oversight may cost you a lot of money. Some insurers add a large deductible to any medical procedure that is not pre-certified. This deductible can be as high as one thousand dollars or more per hospital admission. This means that the insurer will apply this penalty deductible first. After the penalty deductible has been satisfied, additional medical expenses for a hospital stay will still be subject to a patient’s regular deductibles, co-payments, and coinsurance requirements.

Some patients are unable to contact their health insurance companies within the pre-certification time requirement. They might be rushed to the emergency room and admitted for emergency surgery. These patients may be sedated or otherwise unable to take actions on their own such as making phone calls to their insurance companies. In cases such as these, many health insurance companies will retroactively grant pre-certification when the patient is able to pre-certify.

If a health insurance company does not abide by its stated pre-certification requirements, the patient should try to work with the insurer to get the company to honor the stated requirements of its health insurance policy. If a health insurance company is not willing to do the right thing, a patient should formally complain to his state insurance department.


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This post is part of the series: Save Money on Health Care

This series will explore ways to save money in different areas of health care. While health care costs are going up, health insurance companies are providing several different ways to save money on health care.

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