Everything You Need to Know About The Importance of Predetermination

A group of people in a doctor's office learning about the importance of predetermination.
Health insurance is complex even for the savviest of professionals. That’s why consultants are so important for both companies and individuals. At Primary Care Insurance Solutions, one of the most frequently asked questions we receive is what is predetermination?

For many, the first time they hear it is when a doctor recommends a surgical procedure. That procedure must first be approved by the health insurance provider before the physician can set any dates to proceed. But what if you have the choice to move forward with predetermination? Is it really the best option for you? Further still, what is predetermination and why should you care?

The answer might surprise you.

What is Predetermination?

Predetermination for benefits of your health insurance plan is a process through which your insurer’s medical staff reviews the recommended treatment. If they agree with your doctors and specialists that you need the health treatment and that it is right for you, your predetermination is approved. They are typically done before you receive care, which gives you enough time to see if the procedure is covered by your health plan. Ultimately, the decision is made based on the information your doctor provides to your health insurance provider’s medical staff.

For this reason, it is critical that you and your doctor thoroughly explain the procedure in your predetermination letter. Insurance companies tell providers what medical procedures require a predetermination letter before they can be approved. Most of these services include experimental, investigational, or cosmetic services. A few examples of these services might be:

  • Breast Reduction
  • Botox
  • Nasal Surgeries

Anything not deemed life threatening typically falls under the predetermination requirement. Providers must submit the predetermination letter using their letterhead. If they fail to send a letter in with the request for coverage, the claim is likely to be denied.

Your doctor is also required to submit supporting documents. These will include information about previous treatments that were tried and the results of those treatments. A list of all medications administered is another required bit of information from your doctor. Symptoms and your history will need to be included in that letter. Test results, such as MRIs, X-Rays, and diagnostic procedures must be reported to your insurer to guarantee that every alternative option has been pursued.

To see a sample of the predetermination form, please visit this link.

According to the American Medical Association, physicians should submit these letters for any procedure that is frequently denied by the insurer as being deemed “unnecessary.” Depending on the care you require, this process should begin as quickly as possible. To avoid waiting months to have your service covered start this process as soon as your doctor recommends the procedure.

But you might still be wondering why predetermination is good for you. After all, it generally seems like more of a hassle than it is worth. However, at Primary Care Insurance Solutions, we know there are multiple benefits of predetermination for both you and for your insurer.

Benefits of Predetermination

The way that insurers are set up is a third party system. You need the care, your physician recommends treatments and medications, but it is your insurance provider who steps in and determines whether or not those treatments and medications are necessary.

Originally, this system was set up to help you save the greatest amount of money possible. Unnecessary medical procedures and treatments can cost tens of thousands of dollars if left unchecked. The good news is, they don’t have to. Your insurer will use their knowledge to compare recommended treatments with industry practices. If they see that your health requires the treatment, it will be approved. If they see another, more affordable, option for treatment, they will deny the claim.

However, it is not just affordability at stake. Your insurer’s other job is to look out for your health. To protect their policy holders, insurers will investigate health claims made by doctors to see if there is an alternative option that could provide the same or better results with a less invasive process. That also saves you from investing your time and energy on a medical procedure that does not get the results you need.

When your health is at stake, nothing is more important than getting the best care possible. That is what your insurer is trying to help you do, in most instances. Yet, the bottom line does play a role in approval rates.

Despite these benefits, some providers are turning to an alternative to traditional patient-physician relationships: Direct Primary Care. You can read more about that at The Heritage Foundation.

What Happens if a Predetermination is Denied?

If your insurer determines that the requested procedure is either not right for you based on the history of your health or they do not deem it a ‘necessary’ procedure, you have two options to proceed.

The first option is to proceed with the treatment but pay for it completely out of pocket with no assistance from your insurer.

The second option is to file an appeal for the claim. In some instances, an insurer will deny your claim because there was insufficient information submitted either by you or by your physician. You also may not have had enough tests done to determine that the treatment was necessary. There could also be errors in the diagnostic codes sent through.  If you want to appeal, you must first identify why your claim was denied and then follow through by meeting the demands of the predetermination letter.

However, it is important to recognize there is a difference between predetermination and pre-authorization. Let’s briefly examine the difference.

How Predetermination is Different from Preauthorization

Because of the confusion over medical terminology, some patients get confused about the difference between predetermination and preauthorization.

Preauthorization is the process that allows providers to determine if coverage is secured and approved of by the payor for the treatment. In no way does it guarantee reimbursement of the services. Regardless, failing to get preauthorization could cause a non-reimbursement for your treatment. Keep in mind that this process can take up to thirty days to be approved. Pay special attention to your preauthorization number on the document to ensure that that your claim is accurately submitted and reported back to you. To send in an appeal letter you have to have that number, so make sure to keep up with any documentation provided.

Predetermination, on the other hand, gives you complete confidence that your benefits coverage will kick in. This predetermination gives you a peace of mind regardless of the treatment you’ve applied for. However, these requests can also take up to forty-five days for approval.

As a rule, we highly recommend predetermination for both patients and providers. Waiting to get that approval could cause serious coverage issues. Don’t wait!

For more information about predetermination, how it works, what to expect, and how to ensure your request is approved feel free to contact the Primary Care Insurance Solutions team right here in Houston, Texas.

Frequently Asked Questions

What is predetermination in healthcare?

Predetermination in healthcare is a process where your insurer’s medical staff reviews recommended treatments to decide if they are necessary and covered by your plan before you receive care.

How does the predetermination process work?

During predetermination, your insurer’s medical staff assesses the recommended treatment’s necessity and suitability based on information provided by your doctor. If approved, the treatment is covered by your plan.

What should be included in a predetermination letter?

The predetermination letter should thoroughly explain the procedure, provide supporting documents like test results and previous treatments, and be submitted by your doctor with their letterhead.

What types of services typically require predetermination?

Services such as experimental, investigational, or cosmetic procedures, like breast reduction, Botox, and nasal surgeries, often require predetermination due to their non-urgent nature.

What are the benefits of going through the predetermination process?

Predetermination ensures that recommended treatments are covered, avoids unnecessary costs, and safeguards your health by comparing treatments with industry practices for better results.

What happens if a predetermination is denied?

If denied, you can proceed with the treatment at your own expense or file an appeal, addressing issues like insufficient information, diagnostic errors, or inadequate tests.

How is predetermination different from preauthorization?

Predetermination guarantees coverage and peace of mind, while preauthorization confirms if coverage is available but doesn’t ensure reimbursement. Predetermination takes up to 45 days, while preauthorization takes around 30 days.

Why is predetermination important for patients and providers?

Predetermination offers assurance of coverage, avoiding coverage issues, and helping patients and providers plan better for necessary treatments. It’s recommended to prevent delays in treatment and financial uncertainties.

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