These Medicare Advantage Insurers Deny Care the Most - Is Yours One?

Medicare Advantage may help older adults save money in retirement, but high prior authorization denial rates may make getting the care they need a challenge. A new KFF report reveals a significant spread in prior authorization denial rates across Medicare Advantage plans. Some rates are in the low single digits, while others are near 20%.

The report highlights how a plan may affect a retiree's ability to receive medical care, and it comes at a particularly important time as we head into the open enrollment period.

Understanding prior authorization requests and denials

Medicare Advantage plans often require prior authorization, a process in which a doctor or provider must receive approval from the health insurance plan before providing services or prescribing a medication. During the prior authorization process, the insurance provider verifies that the plan covers the service or medication, and the provider may also decide if the care is medically necessary.

Centers for Medicaid & Medicare Services rules require insurers to publish certain data, and the KFF report was based on the review of that data. The report reveals that many Medicare Advantage prior authorizations are denied, and the denial rates vary tremendously among providers.

How Medicare Advantage provider denial rates compare

According to the report, the average denial rate across Medicare Advantage plans for standard authorization requests was 12%. Elevance had a 5% denial rate, the lowest out of all Medicare Advantage plans. In comparison, UnitedHealth Group had the highest denial rate at 17%, more than triple Elevance's denial rate.

Denial rates varied depending on whether a request was standard or expedited. United Health Group, Centene, Kaiser Permanente, and Elevance had somewhat higher denial rates for standard requests compared to expedited requests. CVS and Humana's denial rates were higher for expedited requests than standard requests.

Why appealing may make sense

According to the report, prior authorization denials are rarely appealed, but taking the time to appeal may pay off. The report found that 67% of denials were overturned when they were appealed.

To file an appeal, it may be helpful to include supporting documentation from your doctor, such as medical records and a letter of medical necessity. However, filing an appeal may be time-consuming and overwhelming, so retirees who receive a denial might simply accept the denial and not receive the care. Some retirees may even be unaware that they're able to file an appeal.

The Medicare Advantage post-acute care gap

In June, the HHS Office of Inspector General released a report examining unusually high denial rates among Medicare Advantage providers for post-acute care requests. The analysis found that virtually all Medicare Advantage plans required prior authorization for at least some services, and Office of Inspector General (OIG) reports found that Medicare Advantage insurers denied more than half of prior authorization requests for the most expensive type of post-acute care. Insurers denied 65% of requests for long-term hospital stays and 54% of inpatient rehabilitation facility stay requests.

According to OIG data, United Health, Humana, and CVS denied admission requests at a much higher rate than other Medicare Advantage providers. The companies each denied more than 70% of long-term care requests and more than 50% of inpatient rehab facility requests.

How to appeal a prior authorization request denial

According to KFF data, the majority of appeals are successful in overturning a denial, but many retirees never take the time to appeal.

Before you file an appeal, carefully review your denial letter. It should outline the reason for the denial, the policy or guideline used, and how to appeal the denial. The reason for the denial may inform how you decide to frame your appeal and the information you include. Be sure to provide any supporting information from your doctor that may be helpful, such as studies supporting the treatment.

Most insurance plans allow for at least one internal appeal, and insurers are typically required to respond to the appeal within a specific timeframe. In many cases, urgent care appeals are decided within 72 hours, pre-service claims are decided within 30 days, and post-service claims are decided within 60 days.

Bottom line

The KFF data reveals significant variations between the prior authorization denial rates of various Medicare Advantage insurers. That data suggests that if you have a plan through certain insurers, you might have a more difficult time getting an authorization request approved, which might impact or limit your care. You might want to consider that information before choosing a Medicare Advantage plan.

Medicare's Annual Enrollment Period runs from October 15 through December 7, and that's the main window to compare plans and switch for 2027 coverage. If you're already in a Medicare Advantage plan and want a second chance to change your mind, the Medicare Advantage Open Enrollment Period, January 1 through March 31, allows one additional switch to another Medicare Advantage plan or a return to Original Medicare. Consider checking each plan's prior authorization denial record before the open enrollment period and keep that information in mind as you shop for a plan in 2027. Finding the right health insurance plan may be a money-saving part of your retirement plan.

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