Sometimes a health insurer will require preauthorization of a medical procedure, and as a result may deny that pre-authorization, keeping the patient from getting the care they need, at least initially.
Prior authorization typically is required for medical services, procedures, equipment or medication that the insurance company wants to verify is necessary for patient care.
The care might not be approved right away if there are less costly options, for example. Patients who get the care without approval from the insurance company will be responsible for the full cost.
”Insurers use prior authorization to verify that a service...is medically necessary based on that [patient’s] condition or medical history,” said Shawn Stack, a policy director at the Healthcare Financial Management Association. But that is not the end of the road for the patient if they are among the 6% of requests that are denied after the first try. Patients can take action to get that care as ordered by their physician.”