What’s the news: Medicare Advantage enrollees and their physicians in 2022 saw a larger share of their prior authorization requests denied when compared with previous years, 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.
Data from 2022 showed that 7.4% of all prior authorizations were denied or partially denied—for example, the insurer approved 10 of 14 requested therapy sessions. That’s up from the less than 6% of requests denied in each of the years from 2019–2021, says the report from KFF, an independent health policy research, polling and news organization that until last year was known as the Kaiser Family Foundation.
Full prior authorization denials accounted for the majority of denials each year; meanwhile, the proportion that were partial denials became a smaller and smaller share of the overall denials.
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Why it matters: The KFF analysis of 2022’s 46 million prior authorization requests in Medicare Advantage underscores the need for state and federal lawmakers to reform the time-wasting, care delaying tactic.
Some other key take aways from the KFF analysis:
- The vast majority of requests that were appealed in 2022 were subsequently overturned: 83.2%. This number has also remained steady over the past few years.
- Humana plan enrollees most commonly saw their insurer require prior authorization. Humana had 2.9 prior authorization requests for each enrollee compared with an average of 1.7 requests per enrollee in other plans.
- Medicare Advantage insurers varied in how often they denied prior authorization requests, with CVS denying the most (13%) and Anthem denying the fewest (4.2%).
According to the latest results from the AMA’s annual nationwide survey (PDF) of 1,000 practicing physicians about prior authorization, 94% of physicians reported that prior auth led to delays to patients’ access to necessary care, and 78% of physicians reported that the process can at least sometimes lead to patients abandoning their physicians’ recommended course of treatment.
On top of that, 24% of physicians reported that prior authorization has led to a serious adverse event for a patient in their care. Among the physicians the AMA surveyed, these shares said that prior authorization resulted in a serious or adverse event leading to:
- A patient being hospitalized—19%.
- A life-threatening event or requiring intervention to prevent permanent impairment or damage—13%.
- A patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death—7%.
Prior authorization also adds significant costs to the nation’s health system. According to the AMA survey, prior authorization results in worse patient care, squeezes patients and physicians’ pocketbooks and leads to higher overall use of health care resources.
States have made some progress in passing laws to improve prior authorization, but more needs to be done.
Stay up to date on prior authorization improvements
Get the latest news on the AMA’s fight to eliminate care delays, patient harm and practice hassles.
Learn more: The AMA is advocating for critical national and state-level prior authorization reforms that must be made to improve prior authorization.
At the national level, the AMA strongly supports the Improving Seniors’ Timely Access to Care Act of 2024, bipartisan and bicameral federal legislation that would reform prior authorization procedures in Medicare Advantage.
“I urge everyone to join the AMA’s efforts to pass these commonsense reforms by contacting your members of Congress and voicing your support for this … legislation,” AMA President Bruce A. Scott, MD, wrote in an AMA Leadership Viewpoints column. “Working together, we can protect patients and improve the health of our nation by removing the unnecessary and potentially devastating impediments posed by unduly onerous prior authorization policies.”
An AMA model bill (PDF) can help physicians get started on advocating change in their own state legislatures. Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
Learn more about why the AMA fights to fix prior authorization.
