Medicare Benefit insurers obtained about 46.2 million prior authorization requests in 2022, up from 36.5 million in 2021, in keeping with a latest KFF report. Of these 46.2 million requests, 7.4% (3.4 million) have been denied in complete or partly by MA insurers, in comparison with 5.8% in 2021.

KFF’s evaluation used knowledge submitted by MA insurers to the Facilities for Medicare and Medicaid Providers. Practically all MA enrollees are required to acquire prior authorization for sure providers, akin to high-cost providers, hospitalizations and chemotherapy. The follow has come beneath hearth lately, nevertheless, with lawmakers and different advocates saying it slows down care and burdens docs. To deal with these considerations, CMS finalized three guidelines that goal to make the method extra environment friendly and make clear the factors for prior authorization.

The KFF researchers additionally discovered that of the rejected prior authorization requests in 2022, solely 9.9% have been challenged. That is akin to earlier years, when solely 10.6% of denials have been challenged in 2021.

“The low enchantment price could also be on account of plan members not figuring out they’ll enchantment a denial or discovering the enchantment course of intimidating,” the researchers mentioned. “A earlier KFF examine discovered that many individuals who face denials, together with folks with Medicare, are confused about their protection and don't know how you can enchantment to their plan.”

Whereas appeals are uncommon, the report discovered that the majority are profitable. In 2022, 83.2% of rejected prior authorization requests that have been appealed have been in the end overturned, much like earlier years.

“This raises questions on whether or not the preliminary request ought to have been permitted, though it may additionally point out that the preliminary request lacked the required documentation to justify the service,” the report mentioned. “In each instances, sufferers might have skilled delays in acquiring providers that have been in the end permitted due to the prior authorization course of.”

There may be additionally a number of variation between insurers on the subject of prior authorization. KFF discovered that:

• Humana had essentially the most prior authorization requests per MA enrollee in 2022 (2.9 requests), whereas Kaiser Permanente had the fewest requests (0.5 requests)
• CVS rejected the very best share of requests (13%), whereas Anthem rejected the bottom share (4.2%)
• Cigna had the very best share of denied prior authorization requests that have been appealed (50.4%), whereas Kaiser Permanente had the bottom share (3.5%)
• Centene had the very best share of rejections overturned on enchantment (95.3%), and Humana had the bottom share (68.4%)

“Whereas all Medicare Benefit insurers require prior authorization for not less than some providers, there may be variation throughout insurers and plans within the particular providers topic to those necessities,” the researchers mentioned. “As well as, insurers have the choice to waive prior authorization necessities for sure suppliers, for instance, as a part of risk-based contracts or by way of 'gold carding' packages that exempt suppliers who’ve traditionally complied with the insurer's prior authorization coverage.”

Some insurers are decreasing their prior authorization necessities. LA Care Well being Plan introduced this month that it has eradicated 24% of the codes that require prior authorization. Blue Cross Blue Defend of Massachusetts, Blue Cross Blue Defend of Michigan and Point32Health have additionally lately diminished their prior authorization necessities.

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