Medicare Benefit plans denied 3.4 million prior authorization requests for Health Care providers in complete or partially in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that 12 months, based on a brand new KFF evaluation of federal information.
That was the next share of denials than in recent times. The share of all prior authorization requests denied by Medicare Benefit plans elevated from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021.
Prior authorization is meant to make sure that Health Care providers are medically vital by requiring suppliers to acquire approval earlier than a service or different profit is roofed. Whereas prior authorization has lengthy been used to include spending and stop folks from receiving pointless or low-value providers, IT additionally has been topic to criticism that IT might create boundaries to receiving vital care. (Conventional Medicare doesn’t require prior authorization aside from a restricted set of providers.)
Prior authorization practices have attracted the eye of the Biden Administration and lawmakers in Congress. The administration not too long ago finalized guidelines to extend the timeliness and transparency of prior authorization choices and require Medicare Benefit plans to guage the impact of prior authorization insurance policies on folks with sure social threat components. Lawmakers have launched payments to codify many of those adjustments into regulation.
Different key takeaways from the KFF evaluation embody:
- Only one in 10 (9.9%) prior authorization requests that have been denied have been appealed in 2022. That represents a rise since 2019, when 7.5% of denied prior authorization requests have been appealed.
- The overwhelming majority of appeals (83.2%) in 2022 resulted in overturning the preliminary resolution, much like the shares overturned and in every year between 2019 and 2021.
- Sufferers might have totally different experiences relying on the Medicare Benefit plan wherein they’re enrolled. The amount of prior authorization determinations various throughout Medicare Benefit insurers, as did the share of requests that have been denied, the share of denials that have been appealed, and the share of choices that have been overturned upon attraction.
Two different KFF analyses launched immediately additionally study the most recent information about Medicare Benefit.
- The primary offers Information and developments about present Medicare Benefit enrollment, by plan sort and agency, and by state and county. IT reveals that in 2024, greater than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Benefit. The share of beneficiaries in Medicare Benefit plans varies throughout states starting from 2% in Alaska to 63% in Alabama, Connecticut and Michigan. Medicare Benefit enrollment is very concentrated amongst a small variety of companies, with UnitedHealthcare and Humana accounting for practically half (47%) of all Medicare Benefit enrollment nationwide.
- The second companion evaluation describes Medicare Benefit premiums, out-of-pocket limits, supplemental advantages provided, and prior authorization necessities. In 2024, three quarters (75%) of enrollees in particular person Medicare Benefit plans with prescription drug protection pay no premium apart from the Medicare Half B premium, which is a giant promoting level for a lot of beneficiaries. Most Medicare Benefit enrollees are in plans that supply supplemental advantages not lined by conventional Medicare, resembling imaginative and prescient, listening to and dental. And practically all Medicare Benefit enrollees (99%) are in plans that require prior authorization for some providers.
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