CMS’ Medicare Benefit Policy Manual
The Medicare Benefit Policy Manual is published online by the U.S. Centers for Medicare & Medicaid Services, or CMS. Its used by health care providers, contractors, Medicare Advantage companies and…
Interestingly, the vast majority of appealed denials in MA were overturned, suggesting potential issues with initial determinations. The frequency of prior authorization and denial rates varied significantly across MA insurers.
Virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This contrasts with traditional Medicare, where only a limited set of services, including certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment, require prior authorization (see Box 1).
Prior authorization requirements are intended to ensure that health care services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization and lower costs. This may contribute to their ability to offer extra benefits and reduced cost sharing, typically for no additional premium, while maintaining strong financial performance. At the same time, prior authorization processes and requirements, including the use of artificial intelligence to review requests, may result in administrative hassles for providers, delays for patients in receiving necessary care, and in some instances, denials of medically necessary services, such as post-acute care.
Biniek, J. F., Sroczynski, N., Freed, M., & Neuman, T. (2025, February 6). Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. KFF. https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/
O’Connor, J. (2025, January 31). MA plans’ use of prior authorizations climbs again, despite heightened pressure to limit tactic. McKnight’s Long-Term Care News. https://www.mcknights.com/news/ma-plans-use-of-prior-authorizations-climbs-again-despite-heightened-pressure-to-limit-tactic/
KFF: MA insurers made nearly 50 million prior authorization determinations in 2023. (2025, January 29). American Hospital Association | AHA News. https://www.aha.org/news/headline/2025-01-29-kff-ma-insurers-made-nearly-50-million-prior-authorization-determinations-2023
Lagasse, J. (2025, January 30). Medicare Advantage insurers made about 50 million prior authorization determinations in 2023. Healthcare Finance News. https://www.healthcarefinancenews.com/news/medicare-advantage-insurers-made-about-50-million-prior-authorization-determinations-2023
Gain clarity on the Medicare Advantage payer rates and contract terms bogging down your team and affecting reimbursements.
