May 26, 2022

Understand what services need approval in advance from your insurer; BONUS episode offers tips for brokers and small businesses

Precertification and prior authorization. What is it? When is it needed? Who is responsible for obtaining it? This week’s podcast, “These Boots Are Made for Walking… and they May Have Required Precertification,” answers some of these confusing questions.

Prior authorization—sometimes called precertification or prior approval—is a process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. Charlene, who leads Nova’s client services teams and has more than 15 years of experience working in health insurance, joins “Under the Coverage,” to help clarify the prior authorization process.

She explains that most health plans require some type of prior authorization before covering services such as inpatient surgeries, imaging, home health care and other procedures or durable medical equipment. This means your physician must provide information to the insurance company or administrator for approval to ensure coverage before you obtain the service or item. How the service or equipment is covered is then based on your plan design and provider network.

“More often than not, your physician is going to do a lot of things on their end that you will not have to be involved with, and they’re the ones at the end of the day that do have to submit that information,” Charlene notes, but also recommends people follow up with their insurance company and/or physician, to ensure the necessary documentation was received and to understand the amount covered, particularly before scheduling a surgery or procedure. “Precertification is completely separate from any of your benefits. That’s really going to be based on your benefit designs on what coverage is going to be, so you can call your insurance company and (for example) they can tell you this is subject to your deductible.”

To learn more about the prior authorization/precertification process, tune into this week’s episode.

In addition, a special bonus episode of Under the Coverage, will also be released this week: “Benefits for Small Business.” Looking for guidance on how to build a benefit plan that works for you and your employees? Listen up! In this episode, recommended for brokers, Niko Caparisos of Prosperity Benefits talks about building a benefit plan for small businesses. You don’t need 1,000 employees to get a plan that works for you.  

“How do you save me money?” Caparisos notes is a question frequently asked by employers. “But a lot of times, other things are more important to them, or as important.”

How to Listen

New episodes are added weekly and are available on SoundCloud, Stitcher, Spotify, Apple Podcasts, Google Podcasts, Amazon Music and TuneIn. You can also listen via digital assistants like Alexa, Google and Cortana. Just ask Alexa to, “play the Under the Coverage podcast on Apple Podcasts” (or wherever you get your podcasts).

Under the Coverage features people who spend their working days focused on health benefits and health care, sharing their insider tips on information they wish every health care consumer knew. Have an idea for a future episode or a question you’d like answered? Find Under the Coverage on Twitter @UndrTheCoverage or email podcast@novahealthcare.com.