Most insurers are complying with the public reporting requirements for prior authorization issued by CMS, but whether increased transparency actually helps patients is still an open question.
In consideration of CMS interoperability and prior authorization the final rule requires a subgroup of insurers, on an annual basis, to publicly share certain prior authorization metrics. This rule applies to Medicare Advantage plans, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, and plans in the Affordable Care Act exchanges. It specifically directs the scheme to publish on its websites approval rates, rejection rates and turnaround times for decisions, as well as the results of appeals for medical goods and services except medicines.
state of play
As of April 1, these metrics were available for the three largest Medicare Advantage insurers, unitedhealthcare, humanaAnd Etna.
For UnitedHealthcare Medicare Advantage plans only 2.5% of claims Prior authorization is required, except for a few requests, such as requests for prescription drugs or transitions to post-acute care; 95.4% of such requests are approved, including after appeal. The average time to reach a decision is 24 hours.
“As we have shared in the past, prior authorization remains an important clinical checkpoint that helps ensure care is covered, evidence-based, and safe,” a UnitedHealthcare spokesperson said. The company has also voluntarily published data on commercial, individual and family plan metrics, he said.
Prior authorization in Medicare Advantage has increased in recent years – from 37 million requests in 2019 to more than 46 million in 2022 – with Approximately 53 million determinations by 2024.
Almost all Medicare Advantage beneficiaries Enrolled in plans that require prior authorization for certain services, which are often expensive, such as hospitalization or chemotherapy. In contrast, prior authorization is much less common in traditional Medicare.
A spokesperson for AHIP (formerly America’s Health Insurance Plans) said, “Health plans have made meaningful initial progress in streamlining the use of prior authorization, with more progress being made to enable greater standardization, so that most patients can get answers in real time when their providers electronically submit requests.”
“Now we need our provider partners to integrate this technology into their (electronic health records) and their workflows so we can move beyond fax machines and bring health care technology into the 21st century,” the spokesperson said. Currently offered by phone, fax or mail.
Compliance, not clarity
Insurers are complying with the rule’s requirements, Jenny Fugleston Bieniek, PhD, associate director of the program on Medicare policy at KFF in Washington, D.C., told MedPage Today. “I think there are questions about whether what’s needed is enough to meet the goal of improving transparency,” he said.
One challenge is that there is nothing linking approval or rejection rates to specific services.
For example, a patient with diabetes can determine whether their supplies are subject to prior authorization, she noted. “They can’t see if the plan routinely approves those requests, or if it has a high rejection rate, or how long it takes to get those particular requests approved, because everything here is averaged or aggregated to a very high level.”
one in KFF Quick Take PostKay Pestana, vice president of KFF, where she directs its program on patient and consumer safety, focused on UnitedHealthcare’s reporting, which highlighted approval rates of nearly 80% for Healthcare.gov plans, nearly 92% in Medicaid/CHIP, and 95% in Medicare Advantage.
“Because the information is aggregated across all items and services (except prescription drugs) with no breakdown of what types of services are being approved and what types are being denied, these data provide limited insight into insurers’ prior authorization practices,” they wrote.
Fugleston Bieniak said it is also “quite difficult” for potential nominees to locate the data, noting that she was only able to find the report using very specific search terms in Google. To find the right data for their plan, enrollees need to know what contract the plan they’re enrolled in is part of, he said, “worth knowing, but it’s not obvious.”
For example, one insurer’s website contains more than 20 individual documents detailing Medicare Advantage prior authorization rates, each representing a single contract. Fugleston Bieniek said each contract may involve multiple plans, some of which involve multiple counties or even states.
To compare, an enrollee would have to locate the correct contract on each individual insurer’s website, and even then some enrollment-weighted numbers and high-level math would be necessary, she pointed out.
According to Pestana, another shortcoming of CMS transparency requirements is that since insurers are not required to share why requests are denied, there is no way to find out whether the denial is justified.
Some states, namely Washington and Massachusetts, provide more detailed data on prior authorization, including metrics by service category and even prescription drugs (which the CMS rule excludes). Pestana suggested that the work of those states “could serve as a model for more useful data collection.”
Although it will take some effort on CMS’s part, Fugleston Bieniak said that having a single database and “plan-specific prior authorization rates for some common services” available for download on the agency’s website would go a long way in helping enrollees understand and compare insurers’ behavior on prior authorization.
