Category: Medicare Advantage

If you’re enrolled in a Medicare Advantage plan, you may face a frustrating reality: your doctor orders care, but your insurance company can say no. Medicare Advantage prior authorization denials are far more common than most seniors realize — and a landmark Kaiser Family Foundation study puts the numbers in stark perspective.

Medicare Advantage Prior Authorization Denials by the Numbers

Of the 35 million prior authorization requests submitted by Medicare Advantage enrollees in 2021, two million were fully or partially denied — according to a KFF analysis of data from 515 Medicare Advantage contracts covering 23 million enrollees.

That’s a significant portion of requests for care that a doctor deemed medically necessary, denied by an insurance company’s approval process.

Even more telling: the study found a high frequency of favorable outcomes on appeal. As KFF researchers noted, this raises questions about “whether a larger share of initial determinations should have been approved” in the first place.

Why Medicare Advantage Prior Authorization Is a Problem

In 2022, virtually all Medicare Advantage enrollees (99%) were in a plan that required prior authorization for at least some services. High-cost services most commonly subject to Medicare Advantage prior authorization include:

• Chemotherapy
• Skilled nursing facility stays
• Inpatient hospital admissions
• Durable medical equipment
• Specialist referrals

When a prior authorization is denied, patients face a choice: appeal the decision (which takes time), pay out of pocket, or go without the care their doctor recommended. According to KFF’s research, many patients simply give up after a denial rather than navigating the appeals process.

Original Medicare Doesn’t Have This Problem

Original Medicare does not require prior authorization for most services. If Medicare covers a service and your doctor orders it, it’s covered — no approval process, no delay, no denial.

With a Medicare Supplement Plan G, your share of costs is zero after the Part B deductible. No network restrictions, no prior authorization, no insurance company overruling your doctor.

Questions About Your Medicare Options in Arizona?

I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I help Arizona seniors understand Medicare Advantage prior authorization risks and whether Original Medicare with Plan G is a better fit. My help costs nothing extra.

Call or text: (623) 742-3878
Email: andy@azhealth.us
Fill out the contact form →

Serving Surprise, Phoenix, Peoria, Glendale, Goodyear, Buckeye, Scottsdale, Mesa, Chandler, Gilbert, and all of Arizona.

American Insurance Benefits | 14955 W Bell Rd #8031, Surprise, AZ 85374 | Licensed Arizona Insurance Broker since 2004