Medicare Advantage Plans Deny Larger Share of Pre-Approval Applications in 2022 Than Past Years | KFF

Medicare Advantage plans denied 3.4 million prior authorization requests for health care services in whole or in part in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that year, in follow KFF’s new analysis of federal data.

That was the highest rejection rate in recent years. The share of all first-time claims denied by Medicare Advantage plans increased from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021.

Prior authorization is intended to ensure that health care services are medically necessary by requiring providers to obtain authorization before a service or other benefit is covered. While prior authorization has long been used to limit spending and prevent people from receiving unnecessary or low-quality services, it has also been criticized for creating barriers to access to care. required. (Traditional Medicare does not require prior authorization except for limited services.)

Early approval processes have attracted the attention of the Biden Administration and lawmakers in Congress. The administration recently finalized rules to increase the time and transparency of pre-authorization decisions and require Medicare Advantage plans to evaluate the impact of pre-authorization policies on people with certain social risk factors. Lawmakers have introduced bills to consolidate many of these changes into law.

Other key findings from the KFF survey include:

• Only one in 10 (9.9%) first-time permit applications denied were appealed in 2022. That represents an increase from 2019, when 7.5% of denied permit applications were appealed.
• The majority of appeals (83.2%) in 2022 resulted in the overturning of the first decision, which is the same as that of the shares canceled in each year between 2019 and 2021.
• Patients may have different experiences depending on the Medicare Advantage plan in which they are enrolled. The volume of prior approval decisions varied across Medicare Advantage insurers, as did the proportion of claims that were denied, the proportion of denials that were appealed, and the proportion of decisions that were overturned. petition.

Two other KFF reviews released today also examine the latest information on Medicare Advantage.

• The first provides information and procedures about current Medicare Advantage enrollment, by plan type and firm, and by state and county. It shows that by 2024, more than half (54%) of eligible Medicare beneficiaries will be enrolled in Medicare Advantage. The share of beneficiaries in Medicare Advantage plans varies by state from 2% in Alaska to 63% in Alabama, Connecticut and Michigan. Medicare Advantage enrollment is highly concentrated among a few firms, with UnitedHealthcare and Humana accounting for nearly half (47%) of all Medicare Advantage enrollees nationwide.
• The second spouse review explains Medicare Advantage premiums, out-of-pocket limits, supplemental benefits offered, and prior authorization requirements. By 2024, three-quarters (75%) of enrollees in individual Medicare Advantage plans with prescription drug coverage will have no Medicare Part B copayments, a significant gap of sale to many beneficiaries. Most Medicare Advantage enrollees are in plans that offer additional benefits not covered by traditional Medicare, such as vision, hearing and dental. And nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services.