Prior authorization denials in Medicare Advantage (MA) jumped between 2021 and 2022, according to a new analysis from KFF.
Researchers dived into data from the Centers for Medicare & Medicaid Services and found that 46 million requests for prior auth were submitted to MA insurers in 2022, or about 1.7 requests per enrollee.
Of those requests, 3.4 million or 7.4% were denied, according to the report. By comparison, 5.8% of requests were denied in 2021, as were 5.6% in 2020 and 5.7% in 2019. Meanwhile, the number of requests per enrollee in 2022 was on par with the number submitted in 2019, the study found.
The study noted that there is notable variation between MA plans in terms of how many determinations were made as well as how many were denied.
For example, prior authorization requests were highest for Humana plans, with 2.9 requests per enrollee. Kaiser Permanente plans had the lowest rate at 0.5 requests per enrollee, though the analysis acknowledges that the healthcare giant is something of a unique case given how many services it provides to its own members.
Among traditional insurers, UnitedHealthcare and Cigna were on the low end with 0.9 requests per enrollee.
"Differences across Medicare Advantage insurers in the number of prior authorization requests per enrollee likely reflect some combination of differences in the services subject to prior authorization requirements, the frequency with which contracted providers are exempted from those requirements, how onerous the prior authorization process is for a particular insurer relative to others, and differences in enrollees’ health conditions and the health care services they use," the researchers wrote.
Anthem MA plans had the lowest denial rate at 4.2%, with CVS Health's Aetna at the highest rate of 13%. The analysts said that generally the plans with higher numbers of requests had lower denial rates.
Exceptions to this trend were Centene, which had 2.2 requests per enrollee as well as a denial rate of 9.5%. Cigna had a low rate of submissions as well as a below-average denial rate of 5.8%.
The report also found that it was relatively rare for enrollees to appeal denied claims. Appeal rates ranged from 3.5% for Kaiser Permanente enrollees to 15.2% in Anthem plans. Cigna was, again, an outlier with 50.4% of denials appealed, but the researchers noted that it had both low submission rates and low rates of denials.
When plan members did appeal prior authorization denials, they were frequently successful. For Humana members, 68.4% of appeals were successful, and that rate jumps to 90.8% for CVS and 95.3% at Centene, according to the report.