Depending on the specifics of your private health plan, your insurer may require you to get pre-approval – sometimes called prior authorisation, pre-certification or pre-determination - before you get a prescription for a particular medication or undergo specific procedures.
Pre-approval is effectively a restriction on certain healthcare and medical services, medicines, and tests that mean you and those delivering your care or treatment must get approval before proceeding.
If you don't get pre-approval when you should, your health plan may not cover some or all of the bill, leaving you responsible for paying it yourself.
Why do health insurers require pre-approval?
Pre-approval helps to keep costs low.
While you might think that's to the insurer's benefit, it helps you, too. If you were claiming costs for unnecessary medication, for example, the higher cost of insuring you would ultimately reflect in your future premiums.
Let's examine why health insurers might insist on pre-approval in certain situations.
To ensure you need the treatment or medication
Almost all private health plans exclusively cover medically necessary treatment with very few options, if any, relating to elective treatment.
By requesting pre-approval, your insurer can check reports and other documents from your healthcare provider and ensure the treatment or medication for which you're seeking pre-approval is medically necessary.
To ensure the treatment or medication is recommended and relevant
Medicine is advancing and improving all the time.
As such, your health insurer may seek pre-approval to ensure that the treatment or medication you will receive is the most up-to-date and relevant for your diagnosis.
To ensure it’s the most economical option
It's common for medication to be available under several different brand names. In addition, depending on your condition, there may be numerous potential treatment options for medicine prescriptions and specific procedures.
Pre-approval ensures that your treatment makes financial sense. It won't act as a barrier to you getting the treatment you need.
For example, say medicines A and B were both available to treat your condition, but medicine A is the more expensive. If your healthcare provider prescribes medicine A but cannot provide a medical reason why it's better than medicine B, your insurer may insist you use medicine B instead. Your health insurer may also agree to pay for medicine A, but only if you have already tried medicine B and it didn't have the desired impact.
The same logic may apply to procedures such as scans. For example, an X-ray typically costs less than an MRI, so your health insurer may require pre-approval to ensure your healthcare provider isn't sending you for an MRI when an X-ray would suffice.
To ensure you’re not duplicating services
In some cases, such as receiving treatment for complex or multiple conditions, multiple healthcare providers may be involved in your care.
Suppose a doctor treating one condition asks you to undergo a chest scan. However, you already had a chest scan last month at the request of a doctor treating you for something else. But this doctor may not realise that.
In this scenario, your health insurer will require pre-approval because your doctor may be able to use the results from the scan you already had. If your doctor deems another scan medically necessary, your health insurer would usually provide the pre-approval to proceed.
To ensure ongoing treatment is helping you
After receiving treatment for some time, you expect to see an improvement or change in your condition.
Say you've been taking a particular medication or attending physical therapy for several months. When your healthcare provider wants to issue a new prescription or plan your next block of therapy, your health insurer may ask for a progress update to ensure your treatment has the desired and expected effect.
If your treatment isn’t making you better, or you’re even getting worse, then your health insurer would likely seek updates from your healthcare providers to understand why they recommend this treatment continuing.
What are insurers’ rules around pre-approval?
Every insurer is different, and each health insurer’s rules around pre-approval may differ depending on your plan type and coverage level.
As such, you must know what treatments and procedures require pre-approval.
If you’re a Now Health International member, you can find this information in your Member Handbook.
Are there any laws concerning pre-approval?
Some jurisdictions have specific legislation around pre-approval, including the timeframe in which insurers should respond and the flexibility you have around choosing a healthcare provider for pre-approved care.
Not only will your health insurance company be careful to operate within the laws of each country in which they are present, but they’ll also likely have their own timeframes and commitments for granting pre-approval.
Will I need pre-approval for emergencies?
Usually not. But your insurer may still conduct the pre-approval process retrospectively, and you may need pre-approval for future treatment once the emergency has been dealt with.
How do I get pre-approval?
Each health insurer has its own pre-approval process, but it will typically involve:
- Speaking to your healthcare provider about your treatment and ensuring they know all the information your insurer will need.
- Completing paperwork outlining your condition and treatment needs; this may include adding notes of symptoms and treatment received to date.
- Liaising with your health insurance provider to ensure everything goes smoothly.
Your healthcare provider and insurer will aim to help you get the treatment you need as soon as possible, so try and ensure you're available to provide any additional information if required.
What are my options if my insurer denies a pre-approval request?
This will depend on the reason for the denial.
For example, if there was an error in the submission, you or your healthcare provider might simply need to correct it.
If there were other problems, your options might include:
- Appealing the decision
- Resubmitting the pre-approval application with additional evidence
- Seeking a second medical opinion
- Using a healthcare provider suggested by your insurer, if you’re not already doing so
- Covering the cost yourself
Healthcare providers will often ask you to consider what you'll do if pre-approval isn't granted, so you've started to think about what to do in such a scenario.
Are pre-approval and Direct Billing the same thing?
No. But if your health insurer offers a Direct Billing network, you may have the option to undergo treatment at a Direct Billing facility after receiving pre-approval, meaning you wouldn't need to pay and reclaim your medical expenses.