Debunking the Myths Surrounding Prior Authorization
July 22, 2025 | Tags:
Prior authorization has been an ongoing topic in healthcare, often criticized for delaying care or creating unnecessary barriers. While concerns about access and efficiency are valid, much of the conversation is shaped by misconceptions.
Clarifying common myths about prior authorization can help provide a clearer picture of its role in health insurance and patient care.
What is prior authorization?
Prior authorization is a review process used to ensure that certain proposed healthcare services and prescriptions are medically necessary and appropriate before they are provided. It’s also a way for your health plan to decide if the care requested is safe and cost effective.
Prior authorization is one of the main pillars of managed care that’s used for many reasons:
- It’s a way to manage utilization efficiently.
- It supports high quality and evidence-based treatment decisions.
- It ensures patients receive the right care at the right time.
- It can help reduce unnecessary procedures and healthcare costs.
- It provides early insight into patient care.
For groups and plan members, this means:
- Faster approvals
- More coordinated care
- Fewer unnecessary procedures
- Better management of healthcare needs
Common prior authorization myths and realities
At Medical Mutual, we know that confusion around prior authorization can sometimes lead to challenges between providers, patients and health plans. In this section, we’re clearing up some of the most common myths with facts that reflect our shared goal: delivering the right care, at the right time, and at the right cost.
Myth #1: Health insurance companies make money by denying claims.
Explanation: Almost 15% of claims are initially denied, according to a 2024 Premier study. In many cases, denials result from missing or incomplete information needed for approval. At Medical Mutual, less than 2% of claims are denied. At Medical Mutual, less than 2% of claims are denied. Our teams work with providers in real time to collect the correct information to ensure our members get high-quality care supported by evidence at the right place and the right time
Myth #2: Prior authorization is just another way for insurance companies to make money.
Explanation: Prior authorization ensures individuals receive the right care at the right time. It also gives health plans insight into members’ medical needs. For example, if a Medical Mutual member is scheduled for surgery, prior authorization allows our Customer Care team to prepare early and offer support as soon as the member is discharged.
Myth #3: Insurance companies prioritize cost over physician recommendations and patient’s medical needs.
Explanation: Not all providers consistently stay current with the latest medical guidelines. Medical Mutual’s team of full-time clinicians, nurses, physicians and pharmacists use up-to-date criteria, making them uniquely qualified to help guide providers and ensure our members receive the best possible care.
Myth #4: Insurance companies prioritize profit over people.
Explanation: Many companies focus on their shareholders and the shareholder value. At Medical Mutual, we differentiate ourselves by putting our focus where it matters most: on the people in our community. Every day we prioritize our stakeholders, providers, members, customers and brokers.
Building a better prior authorization process
Medical Mutual is committed to making the prior authorization process more efficient and beneficial for our members so they receive high-quality, necessary care at the right time and place. This means creating faster approvals, fewer unnecessary procedures and better efficiency in managing healthcare needs.
"Prior authorization provides the opportunity to help prepare patients, provide wraparound services and support and then follow-up with them as needed,” said Christian Corzine, Vice President of Clinical Services and Operations at Medical Mutual.
Through our advanced technology platform, developed in partnership with Cohere, Medical Mutual members can expect to receive prior authorization decisions in a timely manner, even as fast as real time. We’re also expanding our prior authorization program to include cardiology, gastroenterology and sleep-related studies, which are significant cost drivers in health insurance.
Interested in learning more about a group plan for your business?
Talk to your broker or a Medical Mutual sales representative for more information, or you can fill out our group quote form.