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 after they use their insurance coverage. Issues tested come with denied claims, community adequacy problems, preauthorization delays and denials, and others. This Information Be aware takes a more in-depth have a look at insured adults who stated that previously 12 months, their medical insurance denied or not on time prior popularity of a remedy, carrier, consult with or drug sooner than they won it, which we can confer with as “prior authorization” issues. A separate Data Note seems at survey findings explicit to the denial of medical insurance claims.

Traits of customers who revel in prior authorization issues

The survey discovered that 16% of all insured adults prior to now 12 months skilled prior authorization issues; and customers with positive traits are much more likely to come across such issues:

Enrolled in Medicaid: About one in 4 (22%) adults insured underneath Medicaid skilled prior authorization issues prior to now 12 months, in comparison to 11% with Medicare, and 15% with employer subsidized protection.

Use extra well being care services and products: Amongst adults who had greater than 10 doctor visits prior to now 12 months, 31% skilled prior authorization issues. This compares to smaller stocks of average customers of well being services and products (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, customers with positive well being stipulations or who use positive kinds of well being services and products are much more likely to revel in prior authorization issues; despite the fact that importantly, survey knowledge can’t establish whether or not prior authorization used to be carried out particularly to those stipulations and services and products:

Psychological well being stipulations: 26% of people that sought remedy for or took prescription medicine for a psychological well being situation prior to now 12 months (e.g., despair, anxiousness) skilled prior authorization issues prior to now 12 months, 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 medicine for diabetes skilled prior authorization issues prior to now 12 months, in comparison to 14% of alternative insured adults.

Prescribed drugs: 19% of adults who recently take no less than one prescription medicine skilled prior authorization issues, in comparison to 8% of those that don’t take prescription medicine.

Emergency services and products: Insured adults who won well being care in an emergency room prior to now 12 months had been about two times as prone to have skilled prior authorization issues, when put next to those that didn’t use the ER (25% vs. 13%). Federal regulation prohibits non-public plans from requiring prior authorization for emergency services and products.

Shoppers with prior authorization issues have a tendency to revel in different insurance coverage issues

Shoppers who skilled prior authorization issues had 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 kinds of medical insurance issues, corresponding to attaining the prohibit on lined services and products, now not having the ability to in finding or get entry to an in-network supplier,  and denied claims. Insured adults total stated they skilled a mean of one.5 several types of insurance coverage issues prior to now 12 months, whilst those that had prior authorization issues skilled about 4 several types of issues, on moderate. Simplest 9% of other folks with prior authorization issues stated this used to be the one form of downside they skilled prior to now 365 days.

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

The survey requested other folks whether or not their insurance coverage issues immediately led to adversarial results corresponding 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 other folks ceaselessly reported experiencing a couple of issues, the knowledge can’t affiliate explicit kinds of insurance coverage issues of explicit penalties. Then again, other folks whose issues incorporated prior authorization had been some distance much more likely to revel in severe well being and monetary penalties in comparison to other folks whose issues didn’t come with prior authorization.

Other people whose issues come with prior authorization had been about thrice much more likely to document being not able to obtain hospital therapy or remedy advisable via a clinical supplier as an instantaneous consequence in their medical 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 document important delays in receiving hospital therapy or remedy as an instantaneous consequence in their issues (32% vs 11%). As well as, other folks whose issues incorporated prior authorization had been about two times as prone to say their well being declined as an instantaneous consequence. (26% v 11%). In the end, greater than a 3rd (37%) whose issues incorporated prior authorization stated they needed to pay extra out of pocket for care.


Prior authorization is a device meant to keep an eye on spending and advertise cost-effective care. Whilst there is not any strategy to inform from the survey whether or not or now not prior authorization denials had been clinically suitable, one-quarter of adults whose insurance coverage issues incorporated prior authorization issues stated their well being standing declined as an instantaneous results of issues that they had with their medical insurance, whilst one-third stated get entry to to wanted care used to be not on time or denied, and greater than one-third stated it led to 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 services and products other folks use in a 12 months, the much more likely they’re to come across prior authorization issues.  Such issues are also skilled disproportionately via other 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 get up extra ceaselessly amongst individuals who use positive services and products, together with emergency services and products (25%) and pharmaceuticals (19%).  Importantly, the survey knowledge don’t establish which services and products or stipulations had 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 services and products are matter to prior authorization and the way ceaselessly it’s granted or denied.  Then again, this regulation stays largely unimplemented, with best partial knowledge on positive in-network services and products amassed from some Inexpensive Care Act market plans.  Contemporary proposed federal rules 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 now not be readily clear to the general public as plans would best be required to document knowledge or effects to the Secretary or to positive plan beneficiaries upon request.

With admire to public protection, Medicare enrollees revel in the bottom fee of prior authorization issues (11%). Then again, a contemporary Inspector Normal audit of this tradition in Medicare Merit (MA) plans discovered 13% of prior authorization denials had been for advantages that are supposed to differently were lined underneath Medicare. (Conventional Medicare most often does now not use prior authorization). The Inspector Normal advisable Medicare must take a more in-depth have a look at the appropriateness of standards utilized by MA plans in making protection determinations. This 12 months CMS finalized new standards for prior authorization and protection selections in Medicare Merit plans.

Just about one in 4 adults insured underneath the Medicaid program say they skilled a previous authorization downside (22%). A contemporary 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 have been denied. It additionally discovered considerable variation in denial charges throughout mum or dad corporations of MCOs, starting from 7% to 41%. The IG advisable more potent state tracking of denials and automated exterior clinical evaluations when such denials are appealed (which occurs now and again). The Biden Management has proposed new regulations round prior authorization that might follow to Medicaid and different protection varieties. Those laws focal point most commonly on streamlining processes and lowering approval wait occasions and feature now not but been finalized.

A variety of state regulatory movements have additionally interested in prior authorization practices. New state rules or updates to current ones have handed in states corresponding 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 avoid prior authorization to restrict delays (e.g. “gold carding”), and restrictions on using scientific standards advanced via insurers to make protection selections. Whilst states have the authority to keep watch over insured plans bought via employers or folks, they lack authority to keep watch over self-insured employer plans, which quilt nearly all of the ones with well being advantages thru a role.

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

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