Medicare Update: List of Insurers Denying the Most Patients Standard Care

Medicare Advantage plans, Medicaid managed care and Affordable Care Act marketplace plans denied at least one in eight standard prior authorization requests last year, according to a new KFF analysis. Denial rates varied from 12 percent in Medicare Advantage to 18 percent in ACA marketplace coverage, with significant differences between insurers.

Kevin Thompson, CEO of 9i Capital Group, expressed shock at the numbers, noting that multiple denials are often necessary for approvals, especially in Medicare Advantage plans. Prior authorization, a process used by insurers to approve treatments and medications, has been a topic of scrutiny for delaying or preventing necessary care.

While most requests are approved, a notable percentage are denied, and many denials are later reversed on appeal. The KFF report, based on insurer data, highlights substantial variation in denial rates among different insurers, suggesting that patients' access to treatment may depend on their insurance card rather than their physician's recommendation.

Appeals result in overturning 67 percent of Medicare Advantage denials, 47 percent of Medicaid managed care denials, and 43 percent of ACA marketplace denials. However, appeals are relatively uncommon, indicating many patients may not receive necessary care without challenging denials. The report follows concerns raised by the U.S. Department of Health and Human Services regarding Medicare Advantage prior authorization practices, with federal investigators finding substantial variation in denial rates for post-acute care services and a high rate of overturned appeals.

Health insurers have been pressured to simplify procedures, but the varying standards raise questions about consistency in applying medical-necessity criteria.