Medicare Advantage Plans Increasingly Deny: You Need To Know How To Get Approvals

What can you do when your Medicare Advantage plan denies care?Photo byAmerican Association for Medicare Supplement Insurance

Jesse Slome is director of the American Association for Medicare Supplement Insurance (AAMSI) a national advocacy organization that supports insurance professionals who market Medicare solutions. This post may include affiliate links. If you purchase anything through these links neither the author nor the Association earn a commission. However, agents who sell Medicare plans do.

If you are one of the 33 million Americans with Medicare Advantage plan coverage, here's information you should know.

More than 46 million prior authorization requests for care or treatment were submitted to Medicare Advantage (MA) insurers on behalf of MA plan enrollees in 2022. That's up from 30 million in 2020.

Medicare Advantage insurers fully or partially denied 3.4 prior authorization requests. Again, this was for 2022 and accounted for 7.4% of prior authorization requests according to a study by Kaiser Family Foundation (KFF). In 2020, only 5.6% of those requests were fully or partially denied.

Medicare Advantage (MA) plans almost always require prior authorization for some services. These mostly are higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. MA plan insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization of care services and lower costs.

When it comes to prior authorizations, here's what you need to know.

Appealing the denial is possible. However, just one in ten (9.9%) prior authorization requests that were denied were appealed in 2022. That does represent an increase from 2019. In that year, some 7.5% of denied prior authorization requests were appealed.

There was good news for many of those who appealed in 2022. The majority (83.2%) resulted in overturning the initial prior authorization denial. This number has more or less held steady over the past few years. But remember, 9 out of 10 do not appeal which is their right.

The KFF analysis reported that the number of prior authorization requests per enrollee ranged from a low of 0.5 requests per enrollee in Kaiser Permanente plans to a high of 2.9 requests per enrollee in Humana plans.

When a Medicare Advantage (MA) beneficiary receives a denial for prior authorization, there are systematic steps that can be taken.

First carefully review the denial notice provided by the insurance company. Then reach out to your healthcare provider or specialist who requested the prior authorization. They may have insights into why the request was denied and can assist in gathering additional information or documentation that supports your case.

If you believe that the denial was unjustified, you have the right to appeal the decision. Most Medicare Advantage plans provide a formal process for appeals. Be sure that you meet any deadlines specified by your MA plan.

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