Precertification Process

The precertification process is a utilization management tool used to control hospital admissions, utilization of services, and medical facility expense. This “tool” must be used uniformly with care, concern, and compassion and with a clear objective that its use does not prevent care needed by pediatric patients.

Children respond to illness and injuries differently from adults. Critical symptoms may develop more rapidly, and children often cannot appropriately communicate the severity of their condition. For these reasons children frequently require early and expedient physician evaluation and in-hospital monitoring. Delay that compromises a child's care or clinical outcome is not acceptable as part of a cost-containment screening process. The timely and appropriate approval of pediatric referrals to hospitals and physicians must be of paramount consideration in any established approval process or procedure. The following guidelines are meant to help achieve the goals of utilization management and optimal care for children.

1. The precertification process must be available in writing for use by the attending physician.

2. The precertification process must be available and clearly presented in all insurance plans and health care contracts so that the parent or guardian is aware of the requirement.

3. Contact telephone approval numbers must be on the patient's insurance card and health care contract. The contracting agency's response personnel must be available 24 hours a day, 7 days a week, including holidays, and must be knowledgeable in pediatric care. Fax or electronic communication should also be available to be used in place of telephone contact as a way to save time.

4. When disagreements about recommended management occur between referring physicians and screening personnel for the health care plan, a system of immediate response by health care plan physicians knowledgeable in pediatric care needs to be in place to resolve the concerns of the referring physician, the parents, or both.

5. If the child's situation is related to an emergency, precertification should be waived as the primary consideration must be to protect the patient's life and health.

6. In the case of a nonacute precertification conflict, an immediate review process by physicians knowledgeable in pediatric care should be available to resolve the problem.

7. Unnecessary delays in treatment must be avoided—most importantly to prevent endangering the patient's life and health and also to reduce excessive nonclinical administrative time required of referring physicians. The health insurance company should compensate the physician's office for all costs involved in performing the work of precertification.

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 children's health care. 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.

Committee on Hospital Care, 1999–2000

• John M. Neff, MD, Chairperson

• Henry A. Schaeffer, MD, Immediate Past Chairperson

• David R. Hardy, MD

• Paul H. Jewett, MD

• John M. Packard, Jr, MD

• Curt M. Steinhart, MD

Liaison Representatives

• Elizabeth J. Ostric

•  American Hospital Association

• Sheila Quinn Rucki, RN, PhD

•  Society of Pediatric Nurses

• Eugene Wiener, MD

• Susan Dull, RN, MSN, MBA

•   National Association of Children's Hospital and Related Institutions

• Jerriann M. Wilson, CCLS, MEd

•  Child Life Council

• Robert Wise, MD

•   Joint Commission on Accreditation of Healthcare Organizations

Consultant

• Mary E. O'Connor, MD, MPH

Section Liaison

• Michael D. Klein, MD

•  Section on Surgery

• Jack M. Percelay, MD, MPH

•  Provisional Section on Hospital Care

• Theodore Striker, MD

•  Section on Anesthesiology

• Copyright © 2000 American Academy of Pediatrics