KFF Digs into MA Prior Authorization Practices

Every week or so there is a new report on Medicare Advantage (MA) prior authorization practices and so Kaiser Family Foundation (KFF) has stepped up and provided an interesting one called “Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain.”

KFF’s research shed light on the issue by focusing on these highlights:

-              MA insurers denied 12 percent of standard prior authorization requests, Medicaid managed care insurers denied 14 percent, and ACA Marketplace insurers denied 18 percent. Denial rates for expedited requests were slightly lower. However, the aggregated approval statistics do not allow for further analysis into which services are being denied, the report said.

-              Prior authorization denials are rarely appealed, but when they are, a considerable share get overturned. Sixty-seven percent of prior authorization denials were overturned upon appeal in MA, 47 percent were overturned upon appeal in Medicaid managed care, and 43 percent were overturned in the ACA Marketplace.

-              Median response times in all markets were about one day for standard prior authorization requests, and about half a day for expedited prior authorization requests for MA, and approximately one day for Medicaid managed care and the ACA Marketplace.

-              Despite the regulatory intent to make insurer prior authorization practices more transparent, difficulty locating and interpreting metrics on insurer websites and gaps in how (e.g., a standardized template that insurers are required to use) and what metrics (e.g., denominators and breakouts by service category) must be reported limit the usability of this information directly by the public, KFF said.

Comments? Contact Patrick Connole at pconnole@parkplacelive.com.