GI - Chapter 7

[Ponderer]

Would someone care enough to explain the following to my enlightenment?

1. What is "corridor deductible?"
2. What is "pre-certification?"

Thanks.

[New at pd]

Corridor deductible: is applied after a preset amount of services has been rendered. For example, a deductible fo $1000 is applied only after benefits have exceeded $5000.

Pre-certification is, by definition, a process by which a patient/physician must gain approval from the plan before services are performed. It's a layer of utilization management. A follow up question I would have is: what exactly is the process? For example, if a physician tries to pre-certify 50 days in a SNF for a member, does the plan fully accept/reject the services, or do they come back with precertifying a lower number of days? If it's the latter, then there would appear to be an issue of excessive services being pre-certified as physicians/members may try to overstate the necessary treatment, which is somewhat contradictory to the point of pre-certification (that of managing utilization.)

[Ponderer]

Pre-certification is, by definition, a process by which a patient/physician must gain approval from the plan <b> before </b> services are performed. It's a layer of utilization management. A follow up question I would have is: what exactly is the process? For example, if a physician tries to pre-certify 50 days in a SNF for a member, does the plan fully accept/reject the services, or do they come back with precertifying a lower number of days? If it's the latter, then there would appear to be an issue of excessive services being pre-certified as physicians/members may try to overstate the necessary treatment, which is somewhat contradictory to the point of pre-certification (that of managing utilization.)

Or better yet, what if the patient calls in for pre-certification? Can one get turned down for going to the doctor office of his/her choice during pre-certification? Then again what is the use of having a non-HMO plan? And I assume pre-certification is required only for non-HMO plans because with HMO the PCP already serves as the utilization control mechanism. I know my new PPO plan requires a pre-certification but we haven't used any benefits from the plan yet.

In your own experience, has anybody ever called in for pre-certifications? What did they actually tell you on the phone?

[New at pd]

Pre-certification is, by definition, a process by which a patient/physician must gain approval from the plan before services are performed. It's a layer of utilization management. A follow up question I would have is: what exactly is the process? For example, if a physician tries to pre-certify 50 days in a SNF for a member, does the plan fully accept/reject the services, or do they come back with precertifying a lower number of days? If it's the latter, then there would appear to be an issue of excessive services being pre-certified as physicians/members may try to overstate the necessary treatment, which is somewhat contradictory to the point of pre-certification (that of managing utilization.)

Or better yet, what if the patient calls in for pre-certification? Can one get turned down for going to the doctor office of his/her choice during pre-certification? Then again what is the use of having a non-HMO plan? And I assume pre-certification is required only for non-HMO plans because with HMO the PCP already serves as the utilization control mechanism. I know my new PPO plan requires a pre-certification but we haven't used any benefits from the plan yet.

In your own experience, has anybody ever called in for pre-certifications? What did they actually tell you on the phone?

I would think that pre-cert could exist in an HMO. Just because there is the gatekeeper system in place (physician referrals) doesn't mean that services are being used efficiently. It seems like patients calling for pre-cert, although used, is probably infrequent, as it may be difficult to estimate the severity of one's own injuries/medical needs.

As an aside, it seems that with pre-cert a cost/benefit analysis would be needed -- you don't want to make the process too elaborate and involved at the risk of adding plan costs.

[Ponderer]

So just exactly what we (as members) call pre-cert for? To get some kind of authorization to see a doctor, or to inform the pre-cert personnel what has happened to us that prompts the call for pre-cert, or any or combo of these or whatever else there may be?

[New at pd]

It doesn't make sense to me either, but the book says that it's used.
I'm surprised it's even allowed at all.