Final answer:
If health insurance prior approval requirements are not met, the payment of the claim is usually denied. This system is part of efforts to manage healthcare costs and resource allocation in both fee-for-service models and HMOs. The ACA sought to address accessibility and affordability, but preauthorization challenges persist.
Step-by-step explanation:
If a health insurance plan's prior approval requirements are not met by providers, the typical consequence is payment of the claim being denied. Providers are expected to obtain this prior approval, sometimes referred to as preauthorization, for certain services to assure the treatment is covered under the health plan and deemed medically necessary. Failing to obtain prior approval can result in patients facing unexpected costs, as insurers may not cover the services rendered without this consent.
In both fee-for-service and health maintenance organizations (HMOs), prior authorizations are a means to control costs and manage resource allocation. The Patient Protection and Affordable Care Act (ACA), also known as Obamacare, aimed to make healthcare more accessible and affordable, but issues like administrative complexities and prior approval requirements remain part of the healthcare landscape, impacting both insured and uninsured individuals.
Adverse selection is another related issue, wherein there is an imbalance due to asymmetric information between insurers and insurance buyers, potentially leading to a situation where those most in need of insurance find it costly or inaccessible.