Surge in MA Prior Authorization Denials: New Study Reveals
A new study highlights significant variation among Medicare Advantage plans regarding the number of determinations made and the frequency of denials. Notably, MA Prior Authorization Denials surged between 2021 and 2022, according to a recent analysis from health policy research.
Researchers examined data from the Centers for Medicare & Medicaid Services and discovered that 46 million prior authorization requests were submitted to MA insurers in 2022, averaging about 1.7 requests per enrollee.
Rising MA Prior Authorization Denials: 7.4% of Requests Rejected in 2022, Study Finds
Of those requests, 3.4 million, or 7.4%, were denied, highlighting the growing issue of Medicare Advantage Prior Authorization Denials, according to the report. By comparison, 5.8% of requests were denied in 2021, 5.6% in 2020, and 5.7% in 2019. Despite the fluctuations in denial rates, the number of requests per enrollee in 2022 remained consistent with the levels seen in 2019, the study found.
The study also noted significant variation between Medicare Advantage plans in terms of the number of determinations made and how many were denied. For instance, Humana plans had the highest rate of prior authorization requests, with 2.9 requests per enrollee. In contrast, Kaiser Permanente plans had the lowest rate, with only 0.5 requests per enrollee, though the analysis points out that Kaiser is somewhat unique due to the extensive range of services it provides directly to its members
Variation in MA Prior Authorization Denials: Insurer Differences Reflect Diverse Policies and Patient Needs
Among traditional insurers, UnitedHealthcare and Cigna were on the lower end, with 0.9 requests per enrollee, emphasizing the variation in Medicare Advantage Prior Authorization Denials.
‘Differences across Medicare Advantage insurers in the number of prior authorization requests per enrollee likely reflect a combination of factors, including the variety of services subject to prior authorization requirements, the frequency with which contracted providers are exempted from those requirements, the relative complexity of the prior authorization process for a particular insurer, and differences in enrollees’ health conditions and the healthcare services they utilize,’ the researchers wrote.
Anthem’s Medicare Advantage plans had the lowest denial rate at 4.2%, while CVS Health’s Aetna had the highest at 13%. The analysts observed that, generally, plans with higher numbers of requests tended to have lower denial rate
Medicare Advantage Prior Authorization Denials and Appeal Success Rates
Exceptions to this trend were seen with Centene, which had 2.2 requests per enrollee and a denial rate of 9.5%, highlighting its role in Medicare Advantage Prior Authorization Denials. Cigna, on the other hand, had both a low rate of submissions and a below-average denial rate of 5.8%.
The report also revealed that it was relatively rare for enrollees to appeal denied claims. Appeal rates varied from 3.5% for Kaiser Permanente enrollees to 15.2% in Anthem plans. Cigna stood out as an outlier with 50.4% of denials appealed, but the researchers noted that it had both low submission rates and low rates of denials.
When plan members did appeal Medicare Advantage prior authorization denials, they were often successful. For Humana members, 68.4% of appeals were successful, with that rate increasing to 90.8% for CVS and 95.3% for Centene, according to the report.
Allzone Management Services: Streamlining Prior Authorization for Reduced Denials
Prior authorization (PA) is a complex and time-consuming process that can lead to significant revenue loss due to denials. This is where Allzone Management Services comes in. We specialize in optimizing the PA process to minimize denials and maximize reimbursement.
Understanding the PA Process
Before diving into solutions, let’s briefly understand the PA process:
- Initiation: The provider identifies a service requiring prior authorization.
- Submission: The provider submits the required documentation to the payer.
- Review: The payer evaluates the request based on medical necessity and coverage criteria.
- Decision: The payer approves, denies, or requests additional information.
- Appeal: If denied, the provider can appeal the decision.
Benefits of Allzone’s PA Services
- Reduced Denials: Our streamlined process minimizes the chances of denials.
- Increased Revenue: Faster approvals and fewer denials lead to improved revenue cycle.
- Improved Patient Satisfaction: Reduced administrative burden results in better patient experience.
- Compliance Adherence: Our experts ensure compliance with all payer regulations.
Conclusion
Allzone Management Services is committed to helping healthcare providers navigate the complexities of the prior authorization process. Our comprehensive approach, combined with advanced technology and experienced professionals, delivers exceptional results.