Dive Brief:
- Nearly 53 million prior authorization requests were sent to payers in 2024 as the number of enrollees in the privatized Medicare program swelled, according to an analysis published Wednesday by KFF. In comparison, payers made almost 50 million prior authorization determinations in 2023.
- That amounts to 1.7 requests on average per MA beneficiary in 2024, a slight decline from 1.8 requests in the previous year, according to the health policy researcher. Nearly 8% of prior authorization requests were fully or partially denied in 2024.
- Enrollees contested only about 12% of denied authorization requests in 2024, but more than 80% of those were partially or fully overturned on appeal. The data suggests patients are facing delays for services that are ultimately approved, according to KFF.
Dive Insight:
Nearly all MA enrollees are subject to prior authorization — where providers have to receive an insurers’ approval before offering a service or medication — for some types of care, according to the health policy researcher. Prior authorization is most common for expensive services, like skilled nursing facility stays or chemotherapy.
Insurers argue the process is key to reducing unnecessary medical spending. But providers say prior authorization frequently delays critical care and can worsen patients’ health.
Prior authorization requests have also received increased scrutiny from regulators and lawmakers. Nudged by the Trump administration, major payers signed a voluntary pledge last year to reform their policies, including by eliminating some prior authorization requests.
Still, the CMS also announced a pilot last year that would require artificial intelligence-backed prior authorization for some services in traditional Medicare — where prior authorization requests in general are much less common.
In 2024, just over 625,000 requests were submitted for traditional Medicare enrollees, amounting to 0.02 submissions on average per beneficiary, according to the KFF report.
Meanwhile, the number of requests in MA are rising as more beneficiaries choose to enroll in the privatized program.
The number of requests, denials and appeals varied across MA insurers, according to the report. Typically, fewer prior authorization requests per enrollee was correlated with a higher share of requests being denied.
For example, major MA insurer UnitedHealth reported 1 request per enrollee in 2024, and denied 12.8% of prior authorization submissions. Meanwhile, Humana had 2.2 requests per enrollee, and denied 5.8%.
Some insurers require more prior authorization
Prior authorization requests per Medicare Advantage enrollee by insurer, 2024
Prior authorization denial rates vary across insurers
Adverse and partially favorable determinations as a share of all prior authorization decisions, 2024
Across insurers, few prior authorization decisions were appealed. The payer with the highest share of appeals was CVS Health at nearly 20%, while the lowest was Kaiser Foundation Health Plan at 1.6%.
When appealed, most decisions were partially or fully overturned across insurers. At the low end, more than half of prior authorization denials were overturned at Kaiser. Centene had the highest share of overturned decisions after an appeal at nearly 96%.
