Consumer Problems with Prior Authorization: Evidence from KFF Survey


A KFF survey of adults with health insurance discovered that kind of 6 in 10 insured adults revel in issues once they use their insurance coverage. Issues tested come with denied claims, community adequacy problems, preauthorization delays and denials, and others. This Information Notice takes a more in-depth have a look at insured adults who mentioned that previously yr, their medical health insurance denied or not on time prior popularity of a remedy, provider, consult with or drug prior to they won it, which we can check with as “prior authorization” issues. A separate Data Note appears to be like at survey findings explicit to the denial of medical health insurance claims.

Traits of customers who revel in prior authorization issues

The survey discovered that 16% of all insured adults previously yr skilled prior authorization issues; and shoppers with positive traits are much more likely to stumble upon such issues:

Enrolled in Medicaid: About one in 4 (22%) adults insured below Medicaid skilled prior authorization issues previously yr, in comparison to 11% with Medicare, and 15% with employer subsidized protection.

Use extra well being care products and services: Amongst adults who had greater than 10 doctor visits previously yr, 31% skilled prior authorization issues. This compares to smaller stocks of reasonable customers of well being products and services (3-10 visits) and occasional customers (2 or fewer visits), who skilled prior authorization issues at charges of kind of 20% and 10%, respectively.

As well as, shoppers with positive well being stipulations or who use positive varieties of well being products and services are much more likely to revel in prior authorization issues; even if importantly, survey knowledge can not establish whether or not prior authorization used to be carried out in particular to those stipulations and products and services:

Psychological well being stipulations: 26% of people that sought remedy for or took prescription drugs for a psychological well being situation previously yr (e.g., melancholy, nervousness) skilled prior authorization issues previously yr, in comparison to 13% of insured adults who didn’t search psychological well being remedy.

Diabetes: 23% of insured adults who sought remedy or took prescription drugs for diabetes skilled prior authorization issues previously yr, in comparison to 14% of alternative insured adults.

Prescribed drugs: 19% of adults who recently take a minimum of one prescription drugs skilled prior authorization issues, in comparison to 8% of those that don’t take prescription drugs.

Emergency products and services: Insured adults who won well being care in an emergency room previously yr have been about two times as prone to have skilled prior authorization issues, in comparison to people who didn’t use the ER (25% vs. 13%). Federal regulation prohibits non-public plans from requiring prior authorization for emergency products and services.

Shoppers with prior authorization issues generally tend to revel in different insurance coverage issues

Shoppers who skilled prior authorization issues have been a lot more prone to have additionally encountered different issues the use of their protection.

Along with prior authorization, the survey requested about explicit varieties of medical health insurance issues, comparable to achieving the restrict on coated products and services, no longer having the ability to in finding or get entry to an in-network supplier,  and denied claims. Insured adults total mentioned they skilled a mean of one.5 several types of insurance coverage issues previously yr, whilst those that had prior authorization issues skilled about 4 several types of issues, on moderate. Most effective 9% of folks with prior authorization issues mentioned this used to be the one form of drawback they skilled previously one year.

Well being and monetary penalties when insurance coverage issues come with prior authorization

The survey requested folks whether or not their insurance coverage issues without delay ended in adversarial results comparable to not on time or denied get entry to to wanted care, a decline in well being standing, or having to pay upper out-of-pocket prices.  As a result of folks frequently reported experiencing a couple of issues, the knowledge can not affiliate explicit varieties of insurance coverage issues of explicit penalties. On the other hand, folks whose issues integrated prior authorization have been a long way much more likely to revel in severe well being and monetary penalties in comparison to folks whose issues didn’t come with prior authorization.

Folks whose issues come with prior authorization have been about thrice much more likely to record being not able to obtain hospital treatment or remedy really helpful via a clinical supplier as a right away end result in their medical health insurance issues in comparison to the ones whose issues didn’t come with prior authorization (34% vs 10%), and about thrice much more likely to record important delays in receiving hospital treatment or remedy as a right away end result in their issues (32% vs 11%). As well as, folks whose issues integrated prior authorization have been about two times as prone to say their well being declined as a right away end result. (26% v 11%). In the end, greater than a 3rd (37%) whose issues integrated prior authorization mentioned they needed to pay extra out of pocket for care.


Prior authorization is a device supposed to keep watch over spending and advertise cost-effective care. Whilst there is not any technique to inform from the survey whether or not or no longer prior authorization denials have been clinically suitable, one-quarter of adults whose insurance coverage issues integrated prior authorization issues mentioned their well being standing declined as a right away results of issues that they had with their medical health insurance, whilst one-third mentioned get entry to to wanted care used to be not on time or denied, and greater than one-third mentioned it ended in upper out-of-pocket prices. Different research point out concerns about using prior authorization via well being plans.

Survey effects recommend that prior authorization issues are extra prevalent amongst insured adults with positive traits.  The extra well being products and services folks use in a yr, the much more likely they’re to stumble upon prior authorization issues.  Such issues are also skilled disproportionately via folks recognized with positive stipulations, together with about 1 in 4 insured adults who sought remedy for diabetes (23%) and psychological well being problems (26%).  Prior authorization issues additionally rise up extra frequently amongst individuals who use positive products and services, together with emergency products and services (25%) and prescribed drugs (19%).  Importantly, the survey knowledge don’t establish which products and services or stipulations have been the topic of prior authorization necessities.

Present regulation authorizes federal regulators to gather from non-public well being plans and make publicly to be had knowledge on which products and services are topic to prior authorization and the way frequently it’s granted or denied.  On the other hand, this regulation stays largely unimplemented, with simplest partial knowledge on positive in-network products and services accumulated from some Reasonably priced Care Act market plans.  Fresh proposed federal laws associated with compliance with the Psychological Well being Parity and Addition Fairness Act (MHPAEA) will require non-public well being plans to internally collect and evaluate data on whether or not positive practices, together with prior authorization necessities, are getting used comparably for behavioral well being and clinical/surgical advantages. Such knowledge would no longer be readily clear to the general public as plans would simplest be required to record knowledge or effects to the Secretary or to positive plan beneficiaries upon request.

With appreciate to public protection, Medicare enrollees revel in the bottom fee of prior authorization issues (11%). On the other hand, a up to date Inspector Normal audit of this custom in Medicare Benefit (MA) plans discovered 13% of prior authorization denials have been for advantages that are meant to in a different way had been coated below Medicare. (Conventional Medicare usually does no longer use prior authorization). The Inspector Normal really helpful Medicare must take a more in-depth have a look at the appropriateness of standards utilized by MA plans in making protection determinations. This yr CMS finalized new standards for prior authorization and protection choices in Medicare Benefit plans.

Just about one in 4 adults insured below the Medicaid program say they skilled a previous authorization drawback (22%). A up to date report via the Inspector Normal of the Division of Well being and Human Products and services reviewed knowledge on greater than 17 million prior authorization request to Medicaid controlled care organizations (MCOs) and located greater than 2 million were denied. It additionally discovered considerable variation in denial charges throughout mum or dad corporations of MCOs, starting from 7% to 41%. The IG really helpful more potent state tracking of denials and automated exterior clinical critiques when such denials are appealed (which occurs occasionally). The Biden Management has proposed new regulations round prior authorization that may follow to Medicaid and different protection varieties. Those regulations focal point most commonly on streamlining processes and lowering approval wait instances and feature no longer but been finalized.

A variety of state regulatory movements have additionally all in favour of prior authorization practices. New state rules or updates to current ones have handed in states comparable to Georgia, Illinois, Washington state, Arkansas and Texas. State necessities come with: new reporting on prior authorization requirements and claims denials, shortened time frames for decision-making, permitting suppliers to circumvent prior authorization to restrict delays (e.g. “gold carding”), and restrictions on using medical standards advanced via insurers to make protection choices. Whilst states have the authority to control insured plans bought via employers or folks, they lack authority to control self-insured employer plans, which duvet the vast majority of the ones with well being advantages thru a task.

This paintings used to be supported partly via a grant from the Robert Picket Johnson Basis. The perspectives and research contained right here don’t essentially replicate the perspectives of the Basis. KFF maintains complete editorial keep watch over over all of its coverage research, polling, and journalism actions.

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