Medicare Advantage
Plans Denied 2 Million Prior Authorization Requests in 2021, About 6% of
Such Requests
Medicare Advantage plans
denied two million prior authorization requests for health care services
in whole or in part in 2021, or about six percent of the 35 million
requests submitted on behalf of enrollees that year, a new KFF
analysis finds.
Prior authorization is intended to ensure that health care services are
medically necessary by requiring providers to obtain approval before a
service or other benefit is covered. While prior authorization has long
been used to contain spending and prevent people from receiving
unnecessary or low-value services, there are some concerns that it may
create barriers to receiving necessary care. (Traditional Medicare does
not require prior authorization except for a limited set of services.)
The
analysis also finds variations in both the volume of prior authorization
requests and denial rates across insurers. In general, insurers with
higher numbers of prior authorization requests denied a lower share of
those requests. The variation across insurers likely reflects differences
in the services subject to prior authorization and the frequency with
which contracted providers are exempted from these requirements, as well
as variations in the use of other tools to manage utilization by plan
enrollees.
Only about 11 percent of
denials of prior authorization requests were appealed, the analysis
finds. However, of the appeals that were filed, the vast majority (82%)
resulted in fully or partially overturning the initial denial.
The high rate of successful appeals raises questions about whether a
larger share of the initial prior authorization requests should have been
approved. Alternatively, it could reflect problems with documentation
that were subsequently rectified during the appeal. In either case,
medical care ordered by physicians or other practitioners ultimately
deemed necessary by the insurers was potentially delayed by the prior
authorization process.
As Medicare Advantage enrollment continues to grow, a better
understanding of prior authorization will help inform how the policy
affects the use of health care services and the quality of the care that
beneficiaries receive.
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