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Medicare Advantage Denials Skyrocket, Appeals Ignored
10 Sep
Summary
- Medicare Advantage plans denied 4.1 million prior authorizations in 2024.
- Nearly 90% of denied patients never challenged their denials.
- Insurers reversed 81% of denials when patients successfully appealed.
In 2024, Medicare Advantage (MA) plans denied 4.1 million prior authorization requests, representing 7.7% of all determinations. Despite this high number, only 11.5% of these denials were appealed by beneficiaries or their providers. When appeals were filed, insurers reversed the initial decision 80.7% of the time.
This substantial reversal rate indicates that many denied requests are ultimately approved upon further review, often with additional documentation from physicians. However, the vast majority of patients, nearly nine out of ten, do not pursue an appeal. This leaves a significant number of individuals without the care deemed medically necessary by their doctors, as they either pay out-of-pocket or receive less care than prescribed.
In contrast, Original Medicare processed fewer prior authorization reviews and had a lower denial percentage, but it applies prior authorization to a much narrower set of services. MA plans utilize this tool more broadly, impacting more treatment decisions. Beneficiaries considering a switch from MA to Original Medicare should be aware of potential complexities with Medigap enrollment and state-specific protections.
