Medicare Advantage Prior Authorization Requests Grew by 13M in 3 Years

The number of prior authorization (PA) determinations made by Medicare Advantage insurers has risen steadily in recent years as enrollment in MA has grown, according to a new KFF analysis.

In 2021, there were 37 million PA determinations, followed by 46 million in 2022 and nearly 50 million in 2023. The increase corresponds to the growing enrollment in MA plans, from 22 million in 2019 to 31 million in 2023.

Nearly all MA enrollees (99%) are subject to PA for some services, particularly high-cost ones including inpatient hospital stays, skilled nursing facility stays and chemotherapy.

In 2023, there were approximately 1.8 PA requests per MA enrollee. Meanwhile, the rate of partial or full PA denials dropped to 6.4% in 2023 from 7.4% in 2022. Of the denied requests, a slightly larger amount (11.7%) were appealed to insurers in 2023 than in recent years. But more than eight in 10 appealed requests were overturned from 2019 through 2023, which raises concerns about unnecessary care delays.

MA members may have varied experiences with PA determinations depending on their health plan, the KFF analysis found. In 2023, Humana Inc. and Elevance Health, Inc. had the largest number of PA requests, both with 3.1 per enrollee, and the lowest denial rates at 3.5% and 4.3%, respectively. Centene Corp. denied the highest share of PA requests at 13.6%, which was significantly higher than its denial rate in 2021 (10.0%).

The KFF analysis suggested that, across most insurers, a higher number of PA requests per enrollee was correlated with a smaller share of requests being denied and vice versa. Centene was an exception, with both a relatively high number of PA requests and the highest denial rate. Fewer than one in five denied PA requests were appealed across all insurers in 2023, ranging from 1.7% for Kaiser Permanente to 18.0% for Cigna Healthcare.

In October 2024, the Senate Homeland Security Permanent Subcommittee on Investigations released a report on PA denials of post-acute care for MA enrollees. The report alleged that Humana, UnitedHealthcare, and CVS Health Corp.’s Aetna denied PA requests for post-acute care at greater rates than they did for other types of care between 2019 and 2022.

Amid growing scrutiny, several major insurers have moved to rework their PA policies over the past few years. UnitedHealthcare and Cigna Healthcare both unveiled plans to eliminate some of their PA requirements. Aetna rolled back PA requirements on cataract surgeries, video EEGs and home infusion for some drugs. Regional health plans, such as L.A. Care, Point32Health and Blue Cross and Blue Shield of Rhode Island, also took steps to reform their PA policies.

Former President Joe Biden’s administration implemented three new regulations related to the use of PA, which required MA plans to clarify the criteria they use to establish PA policies, streamline the PA process, and evaluate the effect of PA policies on people with certain social risk factors.

This article was reprinted from AIS Health’s weekly publication Health Plan Weekly.