If you are enrolled in a Medicare Advantage plan and have ever sought pre-authorization for a recommended medical procedure, you know the pre-authorization process can be time-consuming and too often, unsuccessful. Intended to make sure medical procedures are truly necessary, pre-authorization can result in delays and denials that have drawn increased scrutiny and ire from patients, physicians and lawmakers.
Nine of ten doctors surveyed in a 2022 American Medical Association study report that patients had delayed care while waiting for authorization, and one third reported that patients had become disabled, been hospitalized or died as a result of lengthy pre-authorization delays. In 2021, over 2 million pre-authorization requests were partially or fully denied by Medicare Advantage plans. While only 11% of those denials were appealed, 82% of the appeals were fully or partially overturned, fueling skepticism about the legitimacy of the original denials. According to a 2022 report from the Inspector General of the U.S. Department of Health and Human Services, one in ten denials for service by Medicare Advantage organizations should have been automatically covered under Medicare coverage rules.
In response to growing concerns about the process, in February 2024 the Centers for Medicare and Medicaid Services under the Biden Administration finalized new regulations to reform the pre-authorization process under Medicare Advantage plans. Among the reforms:
- Beginning in 2026, patients seeking prior authorization for non-urgent treatment must get a response within seven calendar days. The current rule is fourteen days.
- Pre-approvals must remain in effect throughout the patient’s medical treatments.
- Starting in 2027, patients who are denied authorization are entitled to get details about the status of their request and the basis for denial, as well as other details, in digital format as well as via regular mail.
The Centers for Medicare and Medicaid Services predict a $15 billion savings under the new rule, generated by better outcomes for patients and reduced governmental administrative costs.
You can find additional information about the new rule here. The AARP has also analyzed how the new rule will impact patients; read it here.
