What can happen if prior authorization is not obtained when required?

Obtaining prior authorization is a critical step for certain medical services and procedures to ensure that insurance coverage is granted. If prior authorization is not obtained when required, the most significant consequence is that the insurance provider may deny coverage for that service. This means that the healthcare provider will not receive reimbursement, and the patient may be responsible for the full cost of the service out-of-pocket.

The process of prior authorization is designed to ensure that the proposed treatment or service is medically necessary and meets the insurance policy's criteria. Without this approval, the insurer has the right to refuse payment, which places financial liability directly on the patient or leaves the provider facing potential loss of revenue.

While other options such as penalties to providers or increased fees for patients could occur in certain circumstances, they are not direct or guaranteed outcomes of failing to obtain prior authorization. The denial of coverage is the most straightforward and immediate consequence related to the failure to secure prior authorization.