Nearly 99% of Medicare Advantage patients are required to obtain prior authorization for certain services.
KFF published an Aug. 8 report breaking down key statistics on Medicare Advantage patients and prior authorization based on data submitted by Medicare Advantage insurers to CMS for 2019 through 2022.
Here are six things to know about prior authorization and Medicare Advantage:
1. More than 46 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of program enrollees in 2022, up from 37 million in 2019.
2. In 2022, there were 1.7 prior authorization requests per Medicare Advantage enrollee, similar to 2019.
3. In 2022, insurers fully or partially denied 3.4 million prior authorization requests or 7.4%. The share of all prior authorization requests that were denied increased from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021 to 7.4% in 2022.
4. Just 1 in 10 (9.9%) prior authorization requests that were denied were appealed in 2022. That represents an increase since 2019, when 7.5% of denied prior authorization requests were appealed.
5. The vast majority of appeals, 83.2%, resulted in overturning the initial prior authorization denial.
6. In 2022, the volume of prior authorization determinations varied across Medicare Advantage insurers, as did the share of requests that were denied, the share that were appealed, and the share that were overturned upon appeal.