Appropriate Care, Gatekeepers, and Pre Certification
This is the part of Managed Care plans that gets much of the bad press, but it’s also the part that controls cost. HMOs, PPOs, and fee for service plans often require pre certification, utilization review, and discharge planning. For example, you may be asked to get authorization or pre certification from your plan or insurer before admission to a hospital for certain types of surgery. Utilization review is the process by which a plan determines whether a specific medical or surgical service is appropriate and/or medically necessary. Discharge planning is a process used to decide what a patient needs for a smooth move from one level of care to another. For example, if, following surgery, you no longer need hospitalization but cannot be cared for at home, you may be transferred to a skilled nursing facility.
The person that performs these functions and makes the decisions is sometimes called the gatekeeper, a term that they are not always fond of. In some plans, part of this function is performed by your primary care physician.
Pre certification is a pain! But it’s a necessary pain. It allows insurance companies to verify that the procedure or treatment is really necessary and can help you screen what’s covered and what isn’t before you run up big bills. Doctors hate it because it can take a long time on the phone, and they often bristle at having to justify their recommendations to the pre-cert nurse that takes their call. However, in many cases it’s like getting a second opinion and can be to your benefit. Some insurance companies have tried to make the process easier by streamlining the process or eliminating the need for certain procedures.