Debunking the Myths Surrounding Prior Authorization
July 10, 2026 | Tags:
Prior authorization is a popular topic in healthcare and is 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 provide a clearer understanding of its role in health insurance and patient care.
What is prior authorization?
Prior authorization is a review process used to help confirm 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 make sure the requested care is safe and cost-effective.
Prior authorization is a key part of managed care and is used for several reasons:
- It provides early insight into patient care.
- It helps reduce unnecessary procedures and healthcare costs.
- It supports high quality and evidence-based treatment decisions.
- It ensures patients receive the right care at the right time.
For employers and members, this means:
- Faster approvals
- More coordinated care
- Better management of healthcare needs
- Fewer unnecessary procedures
Common prior authorization myths and realities
At Medical Mutual, we understand that the confusion surrounding prior authorization can sometimes lead to challenges between providers, patients and health plans. Below are some of the most common myths:
Myth #1: Most claims submitted to health insurance companies are denied.
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. 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 is designed to support quality care and improve the overall member experience, not create barriers to necessary treatment. It ensures individuals receive the right care at the right time and in the most appropriate setting. Medical Mutual's current year-to-date auto-approval rating is over 67%, helping support timely access to appropriate care while reducing the number of requests that require additional review. Prior authorization also provides health plans with valuable insight into members’ healthcare needs so they can offer additional support when needed.
For example, if a Medical Mutual member is scheduled for surgery, the prior authorization process allows our Clinical team to engage with the member before the procedure, enabling us to help coordinate care, identify available resources, support them throughout the treatment journey and assist them with discharge planning to promote the best possible outcomes.
Myth #3: Insurance companies prioritize cost over physician recommendations and patients’ medical needs.
Explanation: While cost is one factor in prior authorization decisions, clinical evidence, nationally-recognized medical guidelines and individual patient circumstances make up the majority. While providers play a critical role in patient care, it can be challenging for any clinician to stay current with the volume of evolving medical research, treatment recommendations and evidence-based guidelines.
Medical Mutual’s team of clinicians, nurses, physicians and pharmacists regularly reviews current clinical criteria and evidence-based standards to support informed, consistent decision making. Throughout the prior authorization process, our clinical experts collaborate with providers to help ensure members receive safe, effective and medically appropriate care that aligns with the latest standards and best practices.
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.
How Medical Mutual is building a better prior authorization process
The health industry is committed to streamlining prior authorization in the next few years, making the process simpler and faster.
Medical Mutual delivers on those goals today. Our commitment to making the prior authorization process more efficient and beneficial for our members allows them to receive high-quality, medically appropriate care at the right time and place. This means delivering faster approvals, fewer unnecessary procedures and better efficiency in managing healthcare needs.
"Prior authorization provides the opportunity to help prepare members and provide the wraparound services and support they need before they need it,” said Christian Corzine, Vice President of Clinical Services and Operations at Medical Mutual.
Through our advanced technology platform, developed in partnership with Cohere Health, Medical Mutual members can expect to receive prior authorization decisions within about a day, and sometimes as fast as real time. We’ve also expanded our prior authorization program to include the following:
- Cardiology
- Gastroenterology
- Sleep-related studies
- Pain Management
- Musculoskeletal
By expanding our program to include these areas, we’re helping to manage high-cost drivers in health insurance and make sure they align with evidence-based care.
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.