Medicare Advantage insurers received about 46.2 million prior authorization requests in 2022, up from 36.5 million in 2021, according to a recent KFF report. Of these 46.2 million requests, 7.4% (3.4 million) were fully or partially denied by MA insurers, compared to 5.8% in 2021.
KFF’s analysis used data submitted by MA insurers to the Centers for Medicare and Medicaid Services. Just about all MA enrollees have to receive prior authorization for certain services, like higher-cost services, inpatient hospital stays and chemotherapy. However, the practice has come under fire recently, with lawmakers and other advocates saying it delays care and burdens physicians. To address these concerns, CMS has finalized three rules that aim to make the process more efficient and clarify the criteria for prior authorization.
The KFF researchers also found that of the prior authorization requests that were denied, only 9.9% were appealed in 2022. This is similar to previous years, with just 10.6% of denials appealed in 2021.
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“The low rate of appeals may be attributed to enrollees not knowing that they can appeal a denial or finding the appeal process intimidating,” the researchers said. “A prior KFF survey found that many people who experience denials, including those with Medicare, are confused by their coverage and don’t know how to file an appeal with their plan.”
While appeals aren’t common, the report showed that most of them are successful. In 2022, 83.2% of denied prior authorization requests that were appealed were ultimately overturned, similar to previous years.
“This raises questions about whether the initial request should have been approved, although it could also indicate that the initial request was missing the required documentation to justify the service,” the report stated. “In either case, patients potentially faced delays in obtaining services that were ultimately approved because of the prior authorization process.”
There is also a lot of variety between insurers when it comes to prior authorization. KFF found that:
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- Humana had the most prior authorization requests per MA enrollee in 2022 (2.9 requests), whereas Kaiser Permanente had the least (0.5 requests)
- CVS denied the highest share of requests (13%), while Anthem denied the lowest share (4.2%)
- Cigna had the highest share of denied prior authorization requests appealed (50.4%), while Kaiser Permanente had the lowest share (3.5%)
- Centene had the highest share of denials that were overturned after an appeal (95.3%), and Humana had the lowest share (68.4%)
“While all Medicare Advantage insurers require prior authorization for at least some services, there is variation across insurers and plans in the specific services subject to these requirements,” the researchers said. “In addition, insurers have the option of waiving prior authorization requirements for certain providers, for example, as part of risk-based contracts or through ‘gold carding’ programs that exempt providers with a history of complying with the insurer’s prior authorization policies.”
Some insurers are cutting down on their prior authorization requirements. L.A. Care Health Plan announced this month that it removed 24% of codes that require prior authorization. Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan and Point32Health have also recently cut down on their prior authorization codes.
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