Medicare Advantage Plans Fielded 35 Million Prior Auth Requests in 2021

— Two million requests denied; reasons for denial remain elusive, according to a new report

by Sophie PutkaEnterprise & Investigative Writer, MedPage Today February 3, 2023

Last Updated February 6, 2023

Over 35 million prior authorization requests were submitted to Medicare Advantage insurers in 2021, according to a new report from the Kaiser Family Foundation (KFF).

Two million of these requests, or 6%, were fully or partly denied, according to Jeannie Fuglesten Biniek, PhD, associate director of the Program on Medicare Policy, and Nolan Sroczynski, MSPH, a data analyst for the Program on Medicare Policy, at KFF.

While only 11% of those denials were appealed, the vast majority (173,000 of 212,000) resulted in full or partial approval of the initial prior authorization request.

Prior authorization is meant to prevent patients from receiving medically unnecessary treatment, as well as to prevent waste. However, many experts argue that having to get a service approved by an insurer before it’s delivered delays and complicates necessary care.

A MedPage Today series published late last year reported on numerous downsides to Medicare Advantage plan enrollment, including care delays and denials due to prior authorization requirements. Some physicians reported that they now take time to explain to beneficiaries that if they choose Medicare Advantage plans because they appear to have no or low monthly premiums, they’re “trading money for access.”

The KFF report comes on the heels of two rules proposed by the Centers for Medicare & Medicaid Services (CMS) in December 2022 meant to address concerns about prior authorization, as well as the passage of legislation in the House of Representatives (though not the Senate) that aimed to reduce delays in care by requiring all Medicare Advantage insurers to establish electronic prior authorization processes.

The first rule proposed by CMS would facilitate the use of electronic health records more often for prior authorization to reduce delays and increase transparency in the process (59% of doctors reported using a phone for medical prior authorizations, and 45% reported using fax, according to a 2021 American Medical Association survey). The second rule would call on Medicare Advantage insurers to make public summaries of medical evidence used to establish the policies or criteria for coverage of services subject to prior authorization rules.

In KFF’s report, Anthem was shown to have the highest number of prior authorization requests, with 2.9 per enrollee, while Kaiser Permanente had the lowest at 0.3. The average was 1.5 requests. The variation is likely due to which services are subject to prior authorization requirements, the authors noted. Insurers also “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,” they added.

Generally, insurers with more prior authorization requests overall denied a lower portion of them — Humana had 2.8 per enrollee and denied 3% — while CVS (0.8 per enrollee) and Kaiser Permanente (0.3 per enrollee) denied 12% of requests.

As for appeals, 20% of CVS denials and 19% of Cigna denials were appealed, compared with 1% of Kaiser Permanente denials. Centene and CVS overturned the most prior authorization denials, at 94% and 90%, respectively.

However, this process that many have said erodes care and burdens physician practices still remains somewhat murky: there were no Medicare Advantage data available by firm on which specific clinical services were most commonly denied, approved, or appealed, although a prior report found that the highest proportions of Medicare Advantage enrollees needed prior authorizations for higher-cost services like durable medical equipment, Part B drugs, and skilled nursing facility stays. This information is key, experts said.

“People who are trying to make decisions about what plan to enroll in don’t know what their experience might be until they’re actually in it,” Fuglesten Biniek told MedPage Today.

In an email, A. Mark Fendrick, MD, director of the University of Michigan’s Center for Value-Based Insurance Design said that “better understanding of whether high- or low-value clinical services undergo prior authorization is a critical step to advance policies that clarify and refocus prior authorization’s core purpose — which is to protect patients from potential harm and unnecessary spending, but do not deter access to necessary care.”

In the report, Fuglesten Biniek and Sroczynski could not evaluate the reasons that prior authorization requests were denied. According to America’s Health Insurance Plans (AHIP), the most common reason for denial is that a clinician did not provide all the necessary clinical information for the prior authorization request.