USA Medicare Advantage prior authorisation rates keep climbing

The number of prior authorisation determinations issued by Medicare Advantage insurers continued to grow in 2023, according to a new report from KFF. 

The report examines data from 2023, the latest year available. That year, Medicare Advantage insurers made 49.8 million prior authorisation determinations, or 1.8 per Medicare Advantage enrolee. 

Virtually all enrolees in Medicare Advantage (99%) are required to obtain prior authorisation for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This contrasts with traditional Medicare, where only a limited set of services, including certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment, require prior authorisation.

Prior authorisation requirements are intended to ensure that healthcare services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilisation and lower costs. 

Medicare Advantage insurers denied 3.2 million, or 6.4%, of prior authorisation requests in 2023.  The percentage of denied prior authorisation requests declined from 2022, when Medicare Advantage insurers denied 7.4% of requests that year. 

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Source: Becker's, 29 January 2025