Insurance Verification and Pre-certification: Two Separate Issues

Health Information Services Revenue Cycle Management

ID-100272857 Over the past several years, orthopedic revenue cycle management has been impacted by the number of changes taking place throughout the healthcare industry. Not only have government programs such as Medicare and Medicaid reduced physician reimbursement, but third-party payers have also implemented negotiated fee-for-service contracts. These changes have a negative impact and tend to result in less than 100% reimbursement for charges accrued.

As if these changes aren’t enough, certain provisions contained within HIPAA have also made claims data submission more stringent. Consequently, many practices are looking for ways to improve their revenue cycle processes.

Insurance verification and pre-certification are two issues in orthopedic practices that can affect reimbursements. Implementing strategic changes in the business processes related to these areas can enhance the bottom line of any practice.

Verification at your practice

The staff that you have assigned to verify your patient’s benefits plays a critical role in your practices reimbursement rate.  Verification may be the most effective method to lowering denials from the payer as they are the ones making decisions that will determine whether you will be paid appropriately for services rendered– if paid at all.  These employees’ must focus not only on obtaining benefit information before a patient arrives for an appointment, but must ensure that the benefit information they obtain is accurate and correct.

The best practices for ensuring that the verification process at your practice works to the optimal level includes the following elements:

  • Identify the best resource use–typically online based on the insurance plan.
  • Initiate the insurance verification process as soon as the patient is scheduled for a procedure.
  • When you require detailed information speak to an insurance company representative rather than perusing the website or using an automated system.
  • Know what questions you need to ask in order to obtain the correct benefits for your patients.

Well-trained staff can get the bulk of this information by simply looking at the insurance ID number, group, or plan on the patient’s insurance card. Make sure that new employees or individuals promoted to the verification staff have the proper training on the appropriate processes.


Pre-certification or pre-authorization has always been a thorn in the side of physicians and their billing staff. According to a study published in the Journal of the American Board of Family Medicine, it is estimated that the cost for prior authorization activities, per full-time equivalent physician to be between $2,161 and $3,430 a year. Many insurance carriers are now requiring pre-authorization for more procedures and services than ever before. In addition, many insurers have made it a policy to disallow retroactive authorizations.

The process of obtaining prior authorization can be challenging and time-consuming. However, getting proper pre-authorization on the front-end before rendering services increases the likelihood of prompt payment and decreases write-offs on the back-end.

If your practice has more than one location, consider creating greater efficiencies by centralizing the responsibility for obtaining pre-certification. You can also seek blanket approval from insurance carriers for a “plan-of-care” for specific conditions and treatment protocols, which minimizes or eliminates the need to call every time for authorization.

The degree to which you effectively manage your revenue cycle will determine the level of success your practice will have. With reimbursements from private insurance carriers and the government on the decline, conduct an evaluation of how you manage your processes, especially as it relates to verification and pre-certification procedures.

After you conduct the assessment, you should have a better understanding of the underlying issues affecting your bottom line. You will now be prepared to take the necessary steps to remove the impediments and improve your revenue cycle processes.