Skilled nursing facilities depend heavily on Medicare Advantage reimbursement and are especially vulnerable to prior authorization denials for post-acute stays. These numbers make a compelling case for systematic appeals workflows: if 83% of overturned denials represent recoverable revenue, the cost of appealing every denial is almost certainly justified.
Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022
Medicare Advantage plans denied 3.4 million prior authorization requests for health care services in whole or in part in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that year, according to a new KFF analysis of federal data. That was a higher share of denials than in recent years. The share of all prior authorization requests denied by Medicare Advantage plans increased from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021. Patients may have different experiences depending on the Medicare Advantage plan in which they are enrolled. The volume of prior authorization determinations varied across Medicare Advantage insurers, as did the share of requests that were denied, the share of denials that were appealed, and the share of decisions that were overturned upon appeal.
— KFF, August 8, 2024
Biniek, Jeannie Fuglesten, et al. “Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022.” KFF, 8 Aug. 2024. https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/.
Medicare Advantage + prior authorizations: 19 numbers to know
KFF released a report Aug. 5 that analyzes prior authorization activity between healthcare providers and Medicare Advantage insurers, based on data submitted by MA insurers to CMS. The report helps quantify the challenges hospital and health system leaders face in securing reimbursement from Medicare Advantage plans. Earlier this year, about half of 135 respondents in a survey of health system CFOs said they were considering dropping Medicare Advantage plans due to “onerous” authorization requirements and high denial rates. More than a dozen have already done so, as followed and reported by Becker’s since 2023.
— Becker’s Hospital Review, August 5, 2024
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