Medicare Advantage insurers ranked by prior authorization denial rates

[Duaine]

Medicare Advantage insurers denied 7.4% of prior authorization requests in 2022, according to data published by KFF.

In a report published Aug. 5, KFF examined data submitted to CMS by Medicare Advantage insurers in 2022.

The number of denials increased slightly from 6% in 2021. CVS Health denied the highest percentage of prior authorization requests in 2021 and 2022. The company denied 13% of prior authorization requests it received in 2022, up from 12% in 2021.

Humana had the highest number of prior authorization requests per member in 2022, at 2.9.

Here's how major MA insurers compare on the number of prior authorizations and denial rates:

Average number of prior authorization requests per member (2022)

Humana: 2.9

Elevance Health (Anthem): 2.6

Anthem BCBS plans: 2.3

Centene: 2.2

Other BCBS plans: 2.0

All other plans: 2.0

CVS Health: 1.1

Cigna: 0.9

UnitedHealthcare: 0.9

Kaiser Permanente: 0.5

Prior authorization denial rates (2022)

CVS Health: 13%

Kaiser Permanente: 10.4%

Centene 9.5%

UnitedHealthcare: 8.7%

Humana: 6.8%

Other BCBS plans: 6.3%

BCBS Anthem: 6.2%

Cigna: 5.8%

A other plans: 5.6%

Elevance Health (Anthem) 4.2%

[EXTERNAL LINK] - Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022 | KFF

 

[InsuranceGuy29]

It's also important to note that most "denials" are not really denials, but they will still be counted and factored in as such, via statistics.

Many times, paperwork is not submitted correctly by doctors offices, clerical errors happen at the insurance office itself, doctor's office staffs don't properly include all needed paperwork (this is a VERY common thing), or the insurance office is simply requesting a little further paperwork.

The vast majority of initial "denials" are overturned upon appeal, even if error isn't involved.

It should also be noted that this is from 2022. Since then, anything automatically covered by original Medicare is now auto-approved on-the-spot and requires absolutely zero review of any kind, thus eliminating any and all chance for error. That started on January 1, 2024.

 

[MedicareWAA]

It's also important to note that most "denials" are not really denials, but they will still be counted and factored in as such via statistics. Many times, paperwork is not submitted correctly by doctors offices, clerical errors happen at the insurance office itself, doctor's office staffs don't properly include all needed paperwork, or the insurance office is simply requesting a little further paperwork. The vast majority of initial "denials" are overturned upon appeal, even if error isn't involved. It should also be noted that this is from 2022. Since then, anything automatically covered by original Medicare is now auto-approved on-the-spot and requires absolutely zero review of any kind, thus eliminating any and all chance for error. That started on January 1, 2024.

Read somewhere that 90% of denied PA are overturned on appeal. That the most common reason for denial is incomplete info sent during the process. I don’t have the source handy but I think it was Kaiser based on govt data.

Then again that doesn’t adjust for all the people who don’t appeal. I guess we can assume most of those were just throwing spaghetti against the wall and the denial wasn’t surprising.