Pediatric Coding Alert

Pediatricians are well aware of how frustrating it can be to refer a patient to a specialist and have to wait while the childs health plan decides whether the referral and/or surgery is appropriate. This process, known as precertification, is used by insurance companies to control costs. While not endorsing precertification, the American Academy of Pediatrics (AAP) has proposed guidelines that could allow optimal access to care. Precertification, according to the AAPs committee on hospital care, is unnecessary and not cost effective, but it is here to stay. For this reason, its important for pediatricians to demand that the process follow certain rules.

The American Academy of Pediatrics believes it is in the best interest of children for all pediatricians to assist in the monitoring and control of the rapidly rising costs of childrens healthcare, states the AAPs committee on hospital care in the August issue of Pediatrics. If this includes the use of precertification mechanisms, then the precertification process should be efficient and not result in delays in the patient receiving any recommended treatment.

Following are the AAPs recommendations regarding precertification:

1. Whatever the precertification process is, the
insurance company must make this available in writing to the pediatrician.

2. Parents must be aware of the precertification
process; insurance companies must present it in policies and contracts.

3. Telephone numbers of insurance company represen-
tatives responsible for approving procedures must be on the patients insurance card; these personnel must be available 24 hours a day, seven days a week and must be knowledgeable about pediatrics.

4. If there is a disagreement between the insurance
company and the pediatrician who is referring a child, there must be a system of immediate response by a representative at the insurance company who is knowledgeable about pediatrics.

5. Precertification must be waived in an emergency.

6. Any unnecessary delays in treatment must be
avoided, not only to protect the patients life and health but to reduce the burdensome administrative
time required of referring pediatricians.

7. The insurance company should compensate the
pediatrician for all costs involved in precertification.