Utilization & Precertification

Should I authorize or not? Good question... Let our PreCertification department help you with that decision.

What purpose does precertification have in the workers' compensation arena? It is a means by which general accepted standards attest that we have made the right decision to authorize a procedure.

Precertification answers questions like "Is this surgery necessary?" or "Could this procedure be done in an outpatient setting?".

The plan must be consistent with the diagnosis or condition yet rendered in a cost-effective manner consistent with national medical practice guidelines regarding the type, frequency, and duration, of the treatment.

Precertification is defined as a formal assessment of the medical necessity, efficiency or appropriateness of a medical provider's treatment plan for an injured party. The treatment plan needs to be consistent with the diagnosis or condition, rendered in a cost-effective manner, and consistent with national medical practice guidelines regarding type, frequency, and duration of treatment.

What is utilization review? It is a means of channeling services that require precertification or a way to direct the bill review process. The process as a whole controls cost and eliminates unnecessary services. How does this impact dollars spent on your claims? If the process is firmly locked in place, all medical claims are subject to constant scrutiny prior to payment or authorization. An ounce of prevention, a pinch of caution is a good receipt to eliminate fraud.