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Healthcare and Prior Authorization

The term prior authorisation has a specific meaning within the concept of health care and health insurance, and has a fundamental effect on virtually all of the procedures and clinical assessments that an individual is likely to come up against in the context of their health insurance policy.

Health insurance differs from other types of insurance policies in a number of ways, but in the context of the term prior authorisation there is a fundamental difference that has to be appreciated. In most other types of insurance, an event or catastrophe occurs, and as long as such event is covered under the terms of the insurance policy, then the insurance company is liable to pay subject to terms and conditions etc. There is an implicit contract between the individual and insurance company, where the individual pays the company some money, and the company pays the individual money if and when an event that is insured against happens.

Health insurance is different. An individual pays the insurance company a premium, and if the individual requires any type of assessment, test or clinical procedure, they essentially have to have the approval of the insurance company before such tests or procedures are carried out.

The scenario can differ widely, depending upon the type of health insurance plan or policy that the individual has, but essentially it runs like this.

The individual will approach their primary care physicians, and together they will talk through whatever the issue or concern may be about the individual's health. The primary care physician and individual may well have a number of ideas about how to proceed and what is involved.

However, before any actual test or procedure can be carried out the approval of the insurance company has to be sought. It is the insurance company that will determine whether or not they believe any test or procedure to be medically necessary, and if they do they will give prior authorisation to such test or procedure been carried out. If they do not believe it to be medically necessary then they are likely to decline the test or procedure, meaning that the individual will either have to pay for it themselves or cannot carry through their desired course of treatment.

As said earlier that are a wide range of scenarios where this applies, and there are often dramatic and highly intense debates, arguments, lawsuits etc about whether or not the insurance company is justified in agreeing or withholding a particular course of treatment. There is no easy answer to this, as insurers reserve the right to effectively decide or decline a particular course of treatment. From their point of view this is crucial in containing costs, and keeping some type of control over their claims expenditure. From an individual's point of view it can be incredibly disheartening where a course of treatment is agreed between a physician and an individual, only for the insurance company to deny it on the grounds of it not being medically necessary. What becomes increasingly important in the context of prior authorisation is for the individual to be fully aware of what their rights are in terms of complaints procedures. The insurance company themselves should have very clear and specific guidelines as to how to appeal any decision, including specified limits as to how long such the process should take. In addition there may well be local or national legislation that gives the individual specific consumer rights that allows them to challenge decisions that may well affect their life, or quality of life.

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