March 2, 2023

Advantage Plans Deny 6% of Treatments

Here’s something you should know about Medicare Advantage plans: the vast majority of these insurance policies require prior approval before a person can receive some medical treatments and services.

Historically, that was not the case, and prior authorizations are still very unusual for people who are enrolled in original Medicare and a Medigap supplement.

But in the case of Medicare Advantage plans, physicians submitted more than 35 million requests for prior authorization to insurers in 2021, and more than 2 million of them – or about 6 percent – were fully or partially denied, according to the Kaiser Family Foundation’s new report on more than 500 Advantage plans.

Only about 11 percent of the denials were appealed, but the vast majority of those appeals succeeded in getting a full or partial reversal of the original denial.

“The high frequency of favorable outcomes upon appeal raises questions about whether a larger share of initial determinations should have been approved,” Kaiser said. The American Medical Association reports that a third of physicians say the lengthy and difficult process of seeking a prior authorization from an insurance company caused “a serious adverse [medical] event in a patient.” …Learn More