More older Americans are fighting back when their Medicare Advantage plan denies a prior authorization request, according to recent report.
In 2022, the rate of appeals requesting a third-party review climbed to 5.6 per 1,000 enrollees, according to the report from the Commonwealth Fund, a foundation whose mission is to promote a high-performing, equitable health care system.
That compares to just 3.1 appeals per 1,000 enrollees in 2016.
The report notes that between 2016 and 2022, appeals associated with clinic and supplemental services doubled while appeals associated with inpatient hospital services nearly tripled. By contrast, the volume of appeals associated with home health, skilled nursing facility care and therapies did not change much.
The Commonwealth Fund says it is unclear whether the surge in appeals is a result of a greater willingness among enrollees to pursue the appeal process or due to an increase in medical services for which Medicare Advantage plans require preapproval.
Medicare Advantage plans deny prior authorization requests for a number of reasons, including determining that:
- A service is not medically necessary.
- The benefit is not covered.
- More cost-effective services are available.
When a Medicare Advantage plan denies a prior authorization request, patients can file an appeal. This rarely happens — but when it does, it often pays off.
In 2021, Medicare Advantage plans denied about 6% of 35 million prior authorization requests, according to a study published in JAMA Health Forum, a journal of the American Medical Association.
Just 11% of these denials were appealed. But of those appeals, 82% resulted in the initial decision being overturned, the study found.
When an enrollee appeals a denial, the Medicare Advantage plan reviews the request as part of an internal procedure. The vast majority of denials — up to three-quarters of them — are overturned at this point, according to the Commonwealth Fund.
If the denial is not overturned, it goes to an independent entity known as the Medicare qualified independent contractor (QIC) for further review.
The QIC then either upholds the denial or overturns it.
In 2022, the QIC overturned just 3% of denials that reached this point in the appeals process, according to the Commonwealth Fund.
The report emphasizes that widespread denials of prior authorization requests can lead to adverse health outcomes for seniors: “Coverage denials are troubling because they may lead to delays in obtaining needed care and potentially result in adverse health outcomes.”
To learn more about the past and present state of Medicare Advantage prior authorization requests, check out:
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