Do Appeals Work?

What You Need to Know

KFF recently released a report analyzing 2023 Medicare Advantage prior authorization data. The key takeaways are:

• MA plans denied (in whole or in part) 6.4% of all prior authorization requests in 2023, a slight reduction from 2022's 7.4% denial rate.
• Healthcare providers appealed only 11.4% of those denials. This means that nearly 90% of denials lead to a patient either (a) not getting the services/items prescribed for them, or (b) receiving different - likely, less costly - services/items.
• While few providers appealed MA plans' prior authorization denials, those that did partially or fully overturned the denial 81.7% of the time. This is consistent with KFF data from 2019-forward showing an appeal win rate of over 80% for those who do appeal.
• Humana and United Healthcare have the highest rate of prior authorizations per member of any Medicare Advantage health plans.
• Centene had the highest prior authorization denial rate of any Medicare Advantage plan at 13.6%. Humana had the lowest at 3.5%.

 What this Means for You

The most obvious takeaway is that if you have the capacity to appeal a Medicare Advantage denial, you should do so. More than 80% of these appeals result in a partial or complete reversal of the original denial.

If you are struggling to efficiently appeal these denials, take the time to step back and assess the specific grounds for denials by both device/service type and by health plan. More often than not, payers deny claims for the same reasons over and over again and you can create templates or use other tools to generate strong appeals more quickly.

Finally, when you've finished that analysis, create a summary that shows which of those denials are based on health plan policy (e.g., failure to satisfy coverage requirements) v. those that are denied due to technical claim deficiencies (e.g., proof of delivery wasn't signed, missing prescription). This will allow you to correct broken internal processes more easily and troubleshoot solutions to more substantive claims documentation issues. 

To read the full KFF report, click here.