MA Plans Denied 6% of Prior Authorization Requests in 2021, Study Finds

McKnight’s Home Care | By Diane Eastabrook
 
Medicare Advantage plans denied in full in or in part 2 million (6%) of 35 million prior authorization requests in 2021, according to a new study by Kaiser Family Foundation. The vast majority of the denials (1.6 million) were denied in full.
 
In a curious twist, the study found the Medicare Advantage Organizations that received the highest number of prior authorization requests had the lowest number of denials in general. For instance, Anthem received the most prior authorization requests at 2.9 per enrollee but denied only about 3% of requests. Conversely, Kaiser Permanente received 0.3 requests per enrollee and denied 12% of those requests. 
 
Overall, 11% of denials were appealed, with CVS and Cigna garnering the most appeals at 20% and 19% respectively. The vast majority of appeals (82%) resulted in the prior authorization being fully or partly granted.  
 
Prior authorization is intended to ensure that healthcare services are medically necessary, requiring healthcare providers to obtain approval before a service or benefit will be covered by the patient’s insurance plan. While the practice has been used to prevent overspending of unnecessary services, there have been concerns that prior authorization has created barriers or delays in receiving care. 
 
Late last year, the Centers for Medicare & Medicaid Services proposed a new rule that would speed up the prior authorization process. Under the plan, MA plans, Medicaid and Qualified Health Plans (QHPs) on the Federally-facilitated Exchanges (FFEs) would be required to respond to urgent requests for healthcare services within 72 hours and standard requests within seven calendar days. The plans would also be required to include a specific reason when denying requests and publicly report certain prior authorization metrics. 
 
CMS Administrator Chiquita Brooks-LaSure said the rule is intended to “improve the care experience across providers, patients and caregivers.” 
 
Last year, the Office of Inspector General accused MA plans of denying or delaying services to patients covered under Medicare.