Final answer:
Without prior authorization, a claim for a service will likely be denied by the insurance company. Prior authorization is necessary to determine the medical necessity of a service, and failure to obtain it violates the insurer's policies. Additionally, charging an actuarially fair premium to a whole group rather than separately could lead to equity issues and financial instability.
Step-by-step explanation:
If a claim for a service that requires prior authorization is sent without obtaining this authorization, the claim will most likely be denied. Health insurance companies require prior authorization for specific services to determine if the procedure is medically necessary and to control costs. When prior authorization is not obtained, the payer (insurance company) has the right to deny payment because the service was not pre-approved as per their policies. It is essential for healthcare providers to ensure that all necessary authorizations are in place before proceeding with a service to avoid denial of payment.
If an insurance company tries to charge the actuarially fair premium to a group as a whole rather than to each group separately, it may face issues with equity and sustainability in the insurance pool. The premiums must reflect the risk of each separate group accurately to avoid cross-subsidization, where lower-risk individuals end up subsidizing the higher risks, which could result in adverse selection and potential financial instability for the insurer.