Pre-Certification in Medical Billing and Why It’s Necessary

Pre-certification in medical billing is the process of obtaining approval from a payer for a healthcare service that a provider plans to render to a patient. It’s a way of checking if the service is a covered benefit in the patient’s health plan, how much coverage is available, and if any prior authorization requirements need to be met.

Why Pre-Certification Is Required

Pre-certification is necessary because it ensures that health care providers are providing services to eligible patients, that those services are medically necessary, and that the services adhere to all accepted standards of care. Without pre-certification, providers could unknowingly provide services that the payer does not cover or that require prior authorization. This not only adds to the provider’s costs, but also could interfere with patient care or put the patient at risk.

Furthermore, pre-certification helps health care plans reduce costs. By reviewing services and ensuring they are medically necessary, health plans can take steps to reduce unnecessary or inappropriate utilization. Also, pre-certification can help providers ensure that they are in compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations.

Conclusion

Pre-certification in medical billing plays an important role in making sure that patients are getting the care they need, that health care providers are compliant with applicable regulations, and that health care plans are curbing costs. By requiring pre-certification for certain services, health care plans and providers can ensure that services are medically necessary and provide a higher quality of care to all involved.