News: MA prior authorization requests, denials on the rise

According to a recent KFF analysis, healthcare organizations are submitting more prior authorization requests to Medicare Advantage (MA) plans than they once were, and more of their requests are getting denied, JustCoding reported .

In 2019, 37.1 million prior authorizations were submitted on behalf of MA enrollees, according to the analysis. The number of requests dropped to 30.3 million in 2020, likely due to a decline in utilization as well as a temporary pause of prior authorization requirements by some insurers during the initial phase of the COVID-19 pandemic. Requests increased to 36.5 million in 2021 and to 46.2 million in 2022. However, an MA enrollment increase from 22 million in 2019 to 28 million in 2022 resulted in approximately 1.7 prior authorization requests per MA enrollee each year.

While the majority of MA prior authorization requests in 2022 resulted in a favorable determination, 7.4% were fully or partially denied, according to the analysis. In comparison, 5.7% of requests were denied in 2019, 5.6% in 2020, and 5.8% in 2021.

Only 9.9% of the denied prior authorization requests were appealed in 2022, but 83.2% of the appealed determinations were eventually overturned, according to the analysis. In comparison, 7.5% of denied prior authorization requests were appealed in 2019 with 81.6% of those appealed determinations overturned.

Editor’s note: This article originally appeared in JustCoding.