Why prior authorization woes haven't disappeared
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Health insurers have spent the past year touting how they've cut pre-treatment review claims, but new data suggests that hasn't eliminated hurdles for patients and doctors.
The big picture: By only approving some, but not all, doctor-ordered care, health plans still can force physicians to revise treatment plans, delay procedures or leave patients paying more out of pocket.
By the numbers: Big health insurers in Medicare Advantage and commercial plans as well as Medicaid denied fewer than 1% of so-called prior authorization requests, according to data from Silna, a software company that provides AI-powered support to providers.
- However, roughly 15% of all requests for physical therapy, occupational therapy and speech therapy were only partially approved, the data shows.
- While the findings represent only a small cross section of all medical services, they raise questions about whether the focus on streamlining and cutting red tape is obscuring an important piece of the patient experience.
- "If we come out and say, hey, prior authorizations are required less, and total denials are less than 1%, you'd be like, 'We solved it. That is fantastic,'" said Silna CEO Jeffrey Morelli.
- "When you talk to the average person walking down the street in New York, they'd say, 'No, this is a problem,'" he said.
Between the lines: A KFF analysis of prior authorizations in Medicare Advantage plans showed about 1 million requests for care were partially denied through prior authorization reviews in 2024, Jeannie Fuglesten Biniek, a KFF deputy program director, told Axios.
- But beyond that, there is little publicly available data breaking down which services are likeliest to be turned down or how those decisions affect patient care.
- The Department of Health and Human Services inspector general report recently found that Medicare Advantage plans in June 2024 overturned nearly all prior authorization denials for skilled nursing or rehabilitative care when they were appealed.
"Health plans follow the most up-to-date clinical guidelines to connect patients with evidence-based care to help regain a pre-surgery function or to improve physical function related to an illness or injury," Chris Bond, spokesman of insurer trade group AHIP, told Axios.
State of play: Prior authorization has been a perennial friction point between providers and patients and payers, with insurers arguing the reviews are needed to control wasteful spending and unnecessary care.
- But persistent complaints about treatment delays and administrative hassles have caught the attention of Congress and the Trump administration, with lawmakers often focusing their ire on Medicare Advantage plans with high denial rates.
- Insurers have tried to avoid the political fallout with voluntary pledges to streamline pre-treatment reviews and lift requirements for certain services, saying they've reduced prior authorizations by 11% over the last year.
The bottom line: Prior authorization faces a "Goldilocks problem" where establishing the right amount of care for a patient is incredibly difficult.
- One option that could get more attention could be a "gold card" system, in which providers can bypass reviews altogether if they adhere to evidence-based care guidelines.
