As prior authorization becomes a growing burden for providers, patients are increasingly facing "retrospective denials" for care despite preapprovals, according to Kaiser Health News.
Four things to know:
1. Retrospective denials often leave patients legally liable for a medical bill, even if insurers originally said their procedure was approved.
2. Some prior authorizations may include text that says, "This is not a guarantee of payment." According to KHN, these clauses can act as a loophole that allows insurers to change their mind on medical necessity after more treatment information becomes available.
3. In other instances, patients sometimes are told that prior authorization isn't required, only to find out after their procedure that their payer actually did want one. This can lead to denials that patients aren't aware of until a bill from their provider arrives.
4. Insurers see the use of prior authorization as a way to prevent medically unnecessary care or treatment that could harm patients, according to KHN. Insurers may use denials to request more information, and it doesn't automatically mean there won't be payment.
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