Many health insurance companies require what is sometimes called pre-authorization or prior authorization before they will agree to pay for certain health care services. If a service is subject to prior authorization, then the doctor will have to show the health insurance company that the treatment is medically necessary before they perform it. Otherwise, the company may not pay for the treatment.
In theory, the point of prior authorization is to save on health costs. It prevents doctors and other medical professionals from taking advantage of health insurers, and patients, by performing and collecting money for services that a patient does not need.
What does the AMA say?
In practice, even the American Medical Association, or AMA, finds pre-authorization to be burdensome and overly used. One of the organization’s concerns is that cost is a driving factor behind many denials of authorization, even when a patient really needs an expensive procedure or medication.
On a related point, the AMA also is concerned that the process often is too rigid. For instance, an insurance carrier may insist on a patient going through several preliminary treatments even when the patient’s caregivers agree that these treatments are little more than a waste of time.
Finally, the AMA also observes that decisions about prior authorization are made by medical professionals who may not have the same experience and knowledge base as the provider recommending the treatment.
Patients may turn to the legal system when insurance companies don’t cooperate
Patients who are struggling to get their health insurance company to authorize an important procedure may feel like they have few options. They do not, after all, have unlimited time to wait for treatment of what may be a serious or even life-threatening medical problem. They also do not have the finances to try to pay for the procedure themselves.
A family in this sort of situation may want to consider their legal options, particularly if internal appeals with the health insurance company have failed.