Medicare Advantage (MA) plans are increasingly relying on prior authorizations, creating significant hurdles for nursing homes and their patients, according to a recent analysis by KFF. This trend continues despite growing scrutiny from federal agencies and lawmakers.
The KFF analysis revealed a stark disparity in prior authorization requirements between MA plans and traditional Medicare. In 2023, MA plans required prior authorizations approximately 125 times more often than traditional Medicare. Specifically, MA plans averaged nearly two prior authorization determinations per enrollee, while traditional Medicare averaged only about 0.01 per enrollee. This translates to nearly 50 million prior authorization requests for MA plans in 2023, a significant jump from 37 million in 2021 and 42 million in 2022.
“We don’t see a change,” Nicole Fallon, vice president of integrated services and managed care for LeadingAge, told McKnight’s Long-Term Care News. “We’re just not seeing plans comply with the terms in the 2024 rule, which is that a prior authorization covers a course of treatment.” This lack of compliance forces nursing homes to pursue concurrent reviews, essentially repeat prior authorizations, adding administrative burden and potentially delaying necessary care. Fallon estimates that there are about two to three concurrent reviews for every patient stay.
This surge in prior authorizations comes despite a 2022 federal report highlighting the routine denial of skilled nursing stays and other services by MA plans. A subsequent 2023 Congressional hearing further amplified these concerns, with Senator Richard Blumenthal (D-CT) accusing MA plans of using technology to deny necessary care for financial gain. A Senate Permanent Subcommittee on Investigations report last fall also found that major MA insurers deliberately denied care to increase profits, with UnitedHealthcare’s denial rate for skilled nursing stays increasing ninefold between 2019 and 2022.
While CMS has attempted to curb this practice through a 2024 rule, experts suggest that these efforts have yet to yield significant results. The KFF analysis also exposed issues with the appeals process. In 2023, MA insurers fully or partially denied 3.2 million prior authorization requests, yet only 11.7% of those denials were appealed. However, of those appealed, a significant 81.7% were overturned, raising questions about the validity of the initial denials. KFF notes that these delays can have negative health consequences for beneficiaries. As the debate continues, the future of prior authorizations in MA plans remains uncertain, with the potential for further regulatory changes under the current administration. The lack of enacted legislation, despite bipartisan support, underscores the complexity of this issue.