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2. An Anatomy of Medical Practice > Precertification and Prior Authorization

Precertification and Prior Authorization

For very expensive procedures such as chemotherapy in the treatment of cancer or outpatient procedures, organizations work directly with insurance companies before the activity actually takes place. This coordination is a process known as precertification. Precertification can provide a level of certainty to the treating organization that the procedure will be paid for by the patient’s insurance company before it is actually performed. Precertification results in a special authorization code that must appear in the billing documents for the patient.

At inpatient facilities this is typically called prior authorization. Practically speaking this is not much different from precertification. This step is normally done for elective and scheduled procedures and also plays a role in drug selection and imaging studies. For traumas and other emergency treatment, time does not permit this step, nor does a lack of insurance disqualify the patient from having the treatment. Under the law, although you can be billed for whatever activities an inpatient site performs on you, if you are at immediate risk of death or severe disability the facility is obligated to provide you treatment regardless of your financial or insurance situation. At large facilities, prior authorization will often be its own department. At smaller and me....


  

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