Inside Your Health: Health insurance authorization

Inside Your Health: Insurance Authorization

Most of us expect that having surgery, getting an MRI, or taking a certain medication is a decision between a patient and their doctor - but insurance companies often require prior authorization and it's the doctors and nurses that work for health insurers that determine whether a patient actually receives that care.

Over 48 million medical claims were denied by health insurance providers in 2021, according to a study published by the Kaiser Family Foundation.

5 EYEWITNESS NEWS anchor Leah McLean sat down with Dr. Archelle Georgiou to discuss what patients should do to get the care they need.

Dr. Georgiou said that 17% of the 243 million in-network claims made in 2021 were denied by insurance providers.

According to the study, denials were made for a variety of reasons, including:

  • Denials due to lack of prior authorization or referral
  • Denials due to an out-of-network provider
  • Denials due to an exclusion of a service
  • Denials based on medical necessity (reported separately for behavioral health and other services)