Medicare advantage saw surge in prior authorization requests in 2023

In a detailed analysis conducted by KFF, trends and changes in the prior authorization processes within Medicare Advantage plans were discussed, particularly focusing on data from 2019 to 2023.

What happened 

KFF analyzed the trends and implications of prior authorization requirements in Medicare Advantage plans from 2019 to 2023. The purpose of this analysis was to assess how these requirements impact healthcare access and administrative processes for both providers and patients, particularly in light of the substantial increase in Medicare Advantage enrollment during this period. 

The analysis utilized data submitted by Medicare Advantage insurers to the Centers for Medicare and Medicaid Services (CMS), focusing on the number of prior authorization requests, denials, and appeals. Central findings revealed the widespread use of prior authorization among Medicare Advantage enrollees, the variation in denial rates and appeal outcomes across different insurers, and the potential administrative burdens these processes impose on healthcare providers. 

By the numbers

1. Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023.
2. Prior authorization requests increased from 37 million in 2021 and 42 million in 2022.
3. In 2023, there were nearly 2 prior authorization determinations per Medicare Advantage enrollee, consistent with levels in 2019.
4. Just under 400,000 prior authorization reviews were completed for traditional Medicare beneficiaries in fiscal year 2023.
5. The denial rate for traditional Medicare was 28.8% in 2023.
6. Only 11.7% of denied prior authorization requests were appealed in Medicare Advantage in 2023, an increase from 7.5% in 2019.
7. About 81.7% of appeals of denied requests were overturned in 2023, compared to less than one-third (29%) for traditional Medicare appeals in 2022.
8. Humana had a denial rate of 3.5%, while Centene had the highest denial rate at 13.6%.
9. The share of appeals resulting in favorable decisions ranged from 42.4% for Kaiser Permanente to 93.6% for Centene.
   
   

What was said 

The KFF brief noted the method for their analysis: “The analysis of Medicare Advantage uses organization determinations and reconsiderations – Part C data from the Centers for Medicare and Medicaid Services (CMS) Part C and D reporting requirements public use file for contract years 2019 – 2021 and the limited data set for contract years 2022 and 2023. Medicare Advantage insurers submit the required data at the contract level to CMS and CMS performs a data validation check.

Data for Medicare Advantage contracts is aggregated to the parent company level. Insurers with less than 2% of total Medicare Advantage enrollment are combined into “others”. BCBS stands for Blue Cross Blue Shield. BCBS plans that are offered by Anthem (Elevance) are grouped together and those offered by all other parent companies are grouped together (BCBS Other). BCBS Anthem contracts are excluded for 2021 and 2023 because they did not pass the data validation checks.”

Related: HIPAA Compliant Email: The Definitive Guide

FAQs

How does CMS ensure compliance with HIPAA among Medicare Advantage plans?

CMS requires Medicare Advantage plans to adhere to HIPAA regulations as part of their contractual obligations. 

Can patients access their health information under HIPAA?

Yes, under HIPAA, patients have the right to access their health information held by healthcare providers and health plans, including those participating in Medicare and Medicaid. 

What measures does CMS take to protect patient data in electronic health records (EHRs)?

CMS promotes the adoption of EHRs through incentive programs while ensuring that these systems comply with HIPAA security standards.