A new study published by KFF examines trends in the number of prior authorization requests, determinations, denials, and appeals for 2019 through 2023.
The analysis is based on data submitted by Medicare Advantage (MA) insurers to the Centers for Medicare & Medicaid Services (CMS).
The report found:
MA insurers made nearly 50 million prior authorization determinations in 2023
KFF said the number of determinations reflects a steady year-over-year increase since 2021 and 2023 as more people enroll in MA plans.
Analysts noted that there were just under 400,000 prior authorization reviews for traditional Medicare beneficiaries submitted to CMS even though the number of people enrolled in MA and traditional Medicare were similar.
MA insurers fully or partially denied 3.2 million prior authorization requests in 2023
More than 90 percent of prior authorization requests were approved in full in 2023, according to the analysis. But 3.2 million requests were fully or partially denied.
KFF study authors said that the number of partial or full denials is a smaller share (6.4 percent) of all requests than in 2022 (7.4 percent).
Even though there were fewer prior authorization reviews for traditional Medicare members, the study found 28.8 percent of those requests were denied in 2023.
Most appeals of prior authorization denials were partially or fully overturned in 2023
Approximately 12 percent of denials were appealed to MA insurers. Most of those appeals (81.7 percent) were partially or fully overturned. The initial requests for care were ordered by a health care provider and ultimately considered necessary but were potentially delayed due to the initial prior authorization decision.
Centene denied the highest share of prior authorization requests, Humana denied the fewest
Centene denied 13.6 percent of requests compared to Humana’s denial of 3.5 percent.