Medicare Advantage prior authorizations by the numbers

Physicians, patients, lawmakers, and government policy makers all have voiced their frustrations about prior authorizations for medical treatment.

The practice is “intended to ensure that health care services are medically necessary by requiring providers to obtain approval before a service or other benefit will be covered by a patient’s insurance,” said a new KFF report that analyzed prior authorization requests to insurance companies in Medicare Advantage plans.

Prior authorization contains spending and prevents patients from receiving unnecessary or low-value services, but there are concerns the practice creates barriers and delays to care, while being complex for patients, physicians, and other providers, the report said.

The report found “only a small share” of denials were appealed, but the insurers overturned the initial denials more than 80% of the time. It raises a question about whether the initial denials should have been approved, or if providers did not supply needed documentation.

“In either case, medical care that was ordered by a health care provider and ultimately deemed necessary was potentially delayed because of the additional step of appealing the initial prior authorization decision, which may have negative effects on beneficiaries’ health,” the report said.

Here are selected findings from the report, “Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021,” published by KFF.