Medicare Advantage prior authorization requests, denials on the rise

Healthcare organizations are submitting more prior authorization requests to Medicare Advantage (MA) plans than they once were, and more of their requests are getting denied, according to a recent KFF analysis.

Over 46 million prior authorization requests were submitted on behalf of MA enrollees in 2022, according to the analysis. In comparison, approximately 37 million requests were submitted in 2019. However, MA enrollment increased from 22 million in 2019 to 28 million in 2022. As a result, there were approximately 1.7 prior authorization requests per MA enrollee each year, according to the analysis.

While the overwhelming majority of MA prior authorization requests in 2022 resulted in a favorable determination, 7.4% were fully or partially denied, according to the analysis. Between 2019 and 2021, less than 6% of requests were denied.

Only 9.9% of the denied prior authorization requests were appealed in 2022, but over 80% of the appealed determinations were eventually overturned, according to the analysis.

CMS has recently taken aim at improving prior authorization processes and reducing the associated administrative burden. Earlier this year, the agency published a final rule designed to automate and streamline prior authorization processes across several of its programs, including MA plans. Effective January 1, 2026, these payers must send prior authorization decisions within a reduced timeframe, provide a specific reason for all prior authorization request denials, and publicly report certain prior authorization metrics annually.

Revenue integrity professionals should review the final rule to ensure their organization is prepared to comply with the new requirements.

Editor’s note: Find more NAHRI resources on prior authorization here.