When an insurance company denies a request for prior authorization, it’s highly likely that physicians and patients won’t appeal the denial.
Just one in 10 prior authorization requests that were denied in 2022 were appealed, according to a recently released KFF analysis of data that Medicare Advantage insurers submitted to the Centers for Medicare & Medicaid Services (CMS) between 2019 and 2022.
The statistic is particularly alarming when one considers that the overwhelming majority of appeals—83.2%—resulted in the insurance company either partially or fully overturning the initial prior authorization denial in 2022. That figure is similar to what the overturn rate was between 2019 and 2021.
Denials and delays in care that result when physicians and patients must go through an appeals process to ultimately get care result in real patient harm. According to data from the most recent AMA prior authorization survey of 1,000 practicing physicians (PDF), among the doctors surveyed:
- 94% said that the prior authorization process always, often or sometimes delays patients’ accessing necessary care.
- 19% said prior auth resulted in a serious adverse event leading to a patient being hospitalized.
- 13% said prior auth resulted in a serious adverse event leading to a life-threatening event or requiring intervention to prevent permanent impairment or damage.
- 7% said prior auth resulted in a serious adverse event leading to a patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death.
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles. As part of that effort, the AMA provided a statement (PDF) to a Labor Department advisory committee last month further detailing the implications of the KFF analysis of prior authorization in Medicare Advantage.
Why aren’t there more appeals?
The AMA prior authorization survey found that fewer than one in five physicians that they surveyed—18% —reported that they always appeal a prior authorization denial. Among the reasons that physicians said they did not appeal adverse decisions:
- 62% said they do not believe the appeal will be successful based on past experience.
- 48% said that patient care cannot wait for the health plan to approve the prior authorization.
- 48% said that they have insufficient practice staff time or resources.
Mississippi internist and addiction-medicine specialist Daniel P. Edney, MD, explained that he has patients who drive two hours to see him and that prior authorization may take two or three days, forcing the patient to go home and come back. In these situations, denials can lead to patients abandoning care.
“For working class families, it’s very typical that they can’t come back,” Dr. Edney said in a moving video that is part of a collection of AMA member physicians sharing their awful experiences with prior authorization in practice.
Testimonials and data from the AMA prior authorization survey help explain why so many physicians said they have insufficient practice staff resources and time to file appeals. The AMA survey found that physicians and their staff on average spend 12 hours each week completing prior authorization requests, with 35% of physicians surveyed saying they have staff who exclusively work on prior authorization—something that not every practice can afford.
The KFF analysis noted that few patients may appeal their denials because Medicare Advantage enrollees may not know that they can appeal or that they may find the appeal process intimidating. This is based on an earlier KFF survey of adults with health insurance that found that “claims denials appear to be connected to the complexity of insurance for consumers.” Half of all insured adults surveyed said they find some aspect of insurance difficult to understand, but that number jumped to eight in 10 among those who experienced a claim denial.
Fighting for Physicians
Get updates on how the AMA is fighting for physicians on critical issues—delivered to your inbox.
Prior authorization must change
The AMA is advocating for critical changes to prior authorization, including insurers reducing the volume of prior authorization and becoming more transparent about what information is required for prior authorization and when.
The AMA says critical national and state-level reforms must be made to improve prior authorization, including gold-carding programs, making prior authorization valid for the length of treatment for those with chronic conditions, and requiring that new health plans honor a previous payer’s prior authorization for a minimum of 90 days.
Find out more with the AMA about why fixing prior authorization means giving doctors a true peer to talk with—stat.
Among the measures the AMA supports is the Improving Seniors’ Timely Access to Care Act of 2024 (H.R. 8702; S. 4532), which is bipartisan and bicameral federal legislation that would reform prior authorization procedures in Medicare Advantage.
