No matter which insurer your policy is with, pre-authorisation of treatment is required and for a very good reason.
There are a number of reasons why the insurers need you to pre-authorise including:
Is the treatment eligible for cover?
When you have been advised by your GP that you need to see a specialist, they would not know if you have any exclusions on your policy. Whether relating to pre-existing conditions or the treatment you need would fall under the general exclusions of your policy.
By calling the insurers claims department, the claims handler would be able to check your cover. They would find out if you have cover available for treatment of this type.
Is the consultant/ specialist recognised and fee assured?
Each insurer has an extensive list of consultants and specialists that are recognised and charge within their own fee guidelines. If your consultant charges over the agreed fee guidelines this could result in a shortfall in payment.
Fee guidelines are the costs that the insurance company has agreed that they will pay for a treatment or consultation. Each medical procedure has a procedure code and each code has an agreed fee.
When you call for a pre-authorisation number, the claims handler would advise you of any fee discrepancies. Where necessary they will offer you an alternative fee assured consultant. You could still opt to see the original consultant. You would however be aware that the costs would not be fully met by your health insurance policy.
Is the hospital or medical facility covered on your policy?
Some insurance companies offer hospital lists either to enhance or as a cost control method of buying a policy. Maybe you have chosen a reduced hospital list. Then want to have your in-patient treatment in one of the higher charging hospitals. It is likely there will be a shortfall in payment because this hospital is not on the list you have chosen.
Your call to the insurer to pre-authorise your treatment would highlight this fact to you. At this stage you could re-arrange your appointment or procedure. You can ensure you are treated in facilities that are within the hospital list you have chosen.
Is the treatment recognised for the condition you have?
For each medical condition there is a recognised medical treatment. Your insurer will have records of what procedures are appropriate to treat that specific condition. If your consultant believes that you need to have a different or additional procedure because of another medical issue or because of irregular circumstances then this would need to be agreed with the insurance company before any treatment takes place.
When you call to pre-authorise the treatment as advised by your consultant, the claims handler would query the treatment recommended. Especially true if this should this be an unusual method of treating that condition. They may require a letter from your consultant confirming why the treatment is not following the normal pathway. This would be required before they will consider authorisation.
As medical treatment in hospital (especially surgical) can be costly, it is essential that you obtain pre-authorisation to avoid any unexpected and costly surprises.
Have you reached the limit of your out-patients cover?
Some people apply a reduced out-patient limit on their policy to help to control the annual premium of their policy. If you have an out-patient limit set and have already used your policy then you could be close to the annual policy out-patient limit.
That one call to the insurance company for pre-authorisation can ensure that you know if you are going to be liable to pay towards the treatment you require.
If you have an out-patient limit of £1000 and have already had consultations and diagnostic tests totalling £900 then you would only have a £100 left in your out-patients benefit limit. It is unlikely that this would cover the cost of one specialist consultation and therefore you would be liable for the difference.
The team at SMP Healthcare can help you follow the right procedure when it comes to pre-authorising your private medical treatment and are happy for our clients to call us to make sure that they are using their policy correctly or if they should be doing something differently. If you would like to work with us, please do not hesitate to get in touch.
Telephone 01245 929129/ 0800 047 0127