Pre-certs  are here to stay and the requirements are certain to increase. In some states, almost every managed care payor requires a pre-cert prior to expensive testing. The time it takes a medical office to procure a pre-cert is significant; most take 30-60 minutes and cost the practice roughly $35 to $50. Complicated surgeries require more pre-cert time and can cost up to $125 in overhead. Currently, the average primary care doctor spends $11,000 in overhead just for staff to procure pre-certs for ordered tests. Upcoming CMS changes may increase primary care payments, but behind the scenes, CMS may also require all medicare patients to be pre-certified prior to testing. The addition of Medicare patients to the pre-cert situation means significant overhead increases for primary care doctors, potentially negating the increase for E and M services.

Specialty practices that rely on revenue from ancillary services are noticing the effect as the pre-certs are often denied (a less expensive alternative is recommended first). The patient eventually gets the test, but a week or two later because they must have the less expensive tests first. We have found that specialty practices that are willing to procure the pre-cert for the PCP are being highly successful in negating the decrease in volume that pre-certs can cause. Practices that do this are offering a value-added service to their referral base that builds goodwill and can significantly increase referrals.

Is the practice of providing the pre-cert to your referral base an inducement? It could be. I always favor a conservative view point when it comes to CMS. Who knows what their requirements will look like, but providing the pre-cert could be a violation. But what about those managed care companies? That’s where it gets kind of gray.

Should you offer pre-cert assistance? Consider your leverage and your practice’s market share in the region. Can they really cancel your contract and service the community? If your leverage is good, then proceed with providing the pre-certs to your referral base. After all, the managed care companies are using a third party to handle the pre-cert because they want the medical information to figure out a way to deny the test. The key seems to be that you must call on behalf of the referring practice when completing the pre-cert.  (It probably makes sense to get written approval to do so from your referring practice.)

So here we are…your ancillary services are down due to pre-cert requirements. Are you sitting back and just letting it happen? Providing the pre-cert to your referral base is good service and it ensures payment. Many practices are providing this service to their referral base and have been doing so for many years. The service is well received and usually results in increased referral volume. Providing the service can be a great marketing tool and it’s most effective when introduced by an educational visit from your practice marketing rep.

Have questions? Let us know in the comments.

This entry was posted on Wednesday, October 28th, 2009 at 7:00 am and is filed under All Posts, Referral Marketing. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.