Analysis Uncovers Key Insights About Insurers’ Medical Advantage Prior Authorization Decisions

Nearly all people who enroll for Medical Advantage plans are expected to secure prior authorization when they need certain services, such as skilled nursing facility care, in-patient stays at hospitals and services that cost a lot, such as chemotherapy. A recent analysis revealed critical insights about MA prior authorizations in 2023. We share some of them in the discussion below.

50 million applications were made for prior authorizations

The data submitted to CMS shows that insurance firms providing MA coverage made 50 million determinations with regard to prior authorization requests. This number conforms to a pattern of steady growth that was observed with each passing year. For example, the prior authorization figure for 2021 stood at 37 million while that of 2022 was 42 million.

It is noteworthy that while traditional Medicare has a similar number of enrollees as Medical Advantage, far fewer prior authorization requests were submitted to CMS, that is, only 400,000 requests.

Per capita prior authorization requests

The analysis shows that the average number of prior authorization requests made by each person under Medicare Advantage was two. This rate is similar to the average number of prior authorization requests for each individual on MA plans in 2019.

Comparatively, traditional Medicare registered just one prior authorization request for every 100 individuals enrolled under this scheme. This could be explained by the small number of healthcare services for which persons enrolled under traditional Medicare have to submit prior authorization requests.

Denied prior authorization requests

The data shows that 3.2m requests for prior authorization were denied by insurers. Such requests were either partially or fully denied by the insurers. This accounts for just 6.4 percent of the total number of prior authorization requests made in that year. A look at 2022 data shows that partially or fully denied prior authorization requests accounted for 7.4 percent of the total number of prior authorization requests submitted that year. This indicates that there was a reduction of denied requests in 2023.

Comparatively, 28.8 percent of all prior authorization requests submitted under traditional Medicare in 2023 were denied.

Appeals after prior authorization requests are denied

Out of all the requests made for prior authorization that were denied, only 11.7 percent were escalated to the appeals process. This indicates a growing trend given that in 2019 just 7.5 percent of denied requests were appealed.

Of the 2023 denied requests that were appealed, 81.7 percent of the appeals resulted in partial or full reversals of the original denied prior authorization request. This is concerning, because it means that individuals that needed care may have delayed to receive the care needed due to the denial and appeals process.

Entities like Astiva Health may wish to go through this detailed analysis and see whether they can find insights that help them to stand out from other Medical Advantage providers within their market.

NOTE TO INVESTORS: The latest news and updates relating to Astiva Health are available in the company’s newsroom at https://ibn.fm/Astiva

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