Final answer:
When providers fail to meet a health insurance plan's prior approval requirements, payment of the claim is typically denied. This non-compliance does not reduce administrative costs, cancel coverage, or result in a fine; it only affects claim reimbursement.
Step-by-step explanation:
If a health insurance plan's prior approval requirements are not met by providers, the usual consequence is that payment of the claim is denied. This means neither the healthcare provider nor the patient receives reimbursement for the services provided. Health Maintenance Organizations (HMOs) and other managed care plans typically have these requirements to manage costs and ensure that the services provided are medically necessary. It is part of an effort to reduce instances of adverse selection and to keep insurance premiums reasonable for all parties involved.
The Patient Protection and Affordable Care Act (ACA), commonly known as Obamacare, made significant changes to the healthcare system, including mandating that all individuals have insurance coverage or pay a penalty, thus attempting to reduce the number of uninsured or underinsured individuals. However, when providers do not comply with prior authorization rules, it does not lead to a reduction in administrative costs, the cancellation of patients' coverage, or a fine to the health plan, but simply the denial of payment.