Prior authorization
How often are prior-authorization denials wrong?
Medicare Advantage denied 6.4 percent of prior authorization requests in 2023, but 81.7 percent of the denials that were appealed got overturned, so most denials that patients actually challenged were wrong.
The problem
Prior authorization has become a national utilization-management layer that shifts clinical time, administrative cost, and access risk onto hospitals, physicians, and patients. The strategic problem is not only denial volume, but weak accountability when denials are overturned, unappealed, or driven by documentation process rather than clinical appropriateness.
The recommendation
Reposition prior authorization as a targeted clinical-control tool rather than a default administrative hurdle. The recommended program is to require plan-level denial and overturn transparency, gold-card low-risk providers, standardize documentation, and audit service lines where overturned denials signal systematic overuse.
How often
Size the denial machine and its direction, the raw rate plus the absolute volume it hides.
Medicare Advantage prior authorization denial rate by year
Share of prior authorization requests denied by Medicare Advantage plans. Only Medicare Advantage is publicly reported at this granularity. Commercial and Medicaid managed-care series are not available. The 2024 point of 7.7 percent, from KFF's 2024 determination data, reverses the 2023 dip.
Read it this way Trace the line year by year: the denial rate climbed from 5.7 percent in 2018 to a peak of 7.4 percent in 2021 and 2022, dipped to 6.4 percent in 2023, then rose again to 7.7 percent in 2024. The single 2023 dip does not establish a lasting improvement, since the rate reversed the very next year. Use this chart to see whether the authorization burden is volume, correctness, appeal friction, or harm, and how that evidence supports targeted reform rather than blanket approval or blanket denial.
⊞ data table⬇ CSV
| Year | MA denial rate % |
|---|---|
| 2018 | 5.7 |
| 2019 | 6.2 |
| 2020 | 6.9 |
| 2021 | 7.4 |
| 2022 | 7.4 |
| 2023 | 6.4 |
| 2024 | 7.7 |
KFF, Medicare Advantage prior authorization determinations, 2023 and 2024 · 2018 to 2024 · source
Is it right?
Interrogate whether the no is correct, using two independent lenses: the appeal funnel, which is self-selected, and OIG's random-sample audit, which is not.
What happens to 1,000 Medicare Advantage prior authorization requests
Modeled per 1,000 requests using published 2023 rates: 6.4 percent denied, 11.7 percent of denials appealed, 81.7 percent of appeals overturned. Most denials are never appealed.
Read it this way Follow the widths left to right: only 7.5 of every 64 denied requests are appealed, and of those, 6.1 are overturned. The chart shows the 56.5 unappealed denials, not the appealed 7.5, are where most denied requests end without a second look. Use this chart to see whether the authorization burden is volume, correctness, appeal friction, or harm, and how that evidence supports targeted reform rather than blanket approval or blanket denial.
Caveat A modeled illustration of real published rates, not a raw per-request count. The 81.7 percent overturn rate applies only to the small appealed slice, which is why unchallenged denials are the larger concern.
⊞ data table⬇ CSV
| From | To | Requests per 1,000 |
|---|---|---|
| 1,000 PA requests | Approved | 936 |
| 1,000 PA requests | Denied | 64 |
| Denied | Appealed | 7.5 |
| Denied | Not appealed | 56.5 |
| Appealed | Overturned on appeal | 6.1 |
| Appealed | Denial upheld | 1.4 |
KFF, Nearly 50 million MA prior authorization requests in 2023, and HHS OIG appeal-overturn data · 2023 · source
Denial overturn rate on appeal, by service type
Share of appealed denials overturned, by service type. A high overturn rate means the original denial was reversed on appeal. Post-acute care for the sickest patients is overturned far more often than the all-denials average.
Read it this way Rank the bars by service type: skilled nursing facility denials are overturned 95 to 97 percent of the time on appeal, far above the 81.7 percent all-denials average, while inpatient rehab (43 percent) and long-term care hospital stays (36 percent) sit below it. The 43 percent inpatient rehab figure is only an average; individual plans in the underlying review ranged from 14 to 86 percent overturned. Use this chart to see whether the authorization burden is volume, correctness, appeal friction, or harm, and how that evidence supports targeted reform rather than blanket approval or blanket denial.
Caveat The inpatient rehab figure of 43 percent is an average. Across the 19 MA plans reviewed, IRF overturn rates ranged from 14 to 86 percent. naviHealth, a delegated contractor, processed about half of the SNF reviews.
⊞ data table⬇ CSV
| Service type | Overturned on appeal % |
|---|---|
| SNF admission (naviHealth contractor) | 97 |
| SNF admission (all MA plans) | 95 |
| All MA denials (2023) | 81.7 |
| Inpatient rehab (IRF) | 43 |
| Long-term care hospital (LTCH) | 36 |
HHS OIG post-acute prior-authorization reviews (OEI-09-24-00330, OEI-09-24-00331) and KFF 2023 appeal data · 2023 to 2024 · source
Why, and who pays
The reasons behind denials and the human cost they land on: patient harm and physician administrative burden.
Why prior authorizations get denied
Share of denials by reason. Step therapy and missing-documentation defects are process barriers, not clinical judgments, and together account for 35 percent of denials.
Read it this way Read the bars by share of denials: medical necessity (31 percent) and step therapy (22 percent) are the two largest categories. Step therapy and missing documentation together add up to 35 percent of denials, process barriers rather than clinical judgment, but the chart cannot show whether any individual denial was ultimately correct. Use this chart to see whether the authorization burden is volume, correctness, appeal friction, or harm, and how that evidence supports targeted reform rather than blanket approval or blanket denial.
Caveat A synthesized categorization hand-curated from KFF, ProPublica, and AMA sources, not insurer-reported counts from a single dataset.
⊞ data table⬇ CSV
| Reason | Share of denials % |
|---|---|
| Medical necessity | 31 |
| Step therapy (fail first) | 22 |
| Site of care | 14 |
| Missing documentation | 13 |
| Coding or formulary | 11 |
| Quantity or duration limits | 9 |
AMA and ProPublica, synthesized denial-reason taxonomy · 2023 · source
Physician-reported patient harm from prior-authorization delays
Physician-reported harm from prior-authorization delays, from most to least common. The gradient runs from delays that nearly all physicians report to catastrophic outcomes a smaller share report.
Read it this way The bars run from the most-reported harm to the least: 94 percent of physicians report delays and 78 percent report care abandonment, while the more severe outcomes, hospitalization (25 percent), permanent harm (19 percent), and death (7 percent), are reported by far fewer. These are physician-reported shares of at least one occurrence, not the rate at which any given patient experiences harm. Use this chart to see whether the authorization burden is volume, correctness, appeal friction, or harm, and how that evidence supports targeted reform rather than blanket approval or blanket denial.
Caveat These are shares of physicians who report at least one such event, not the rate at which patients experience them.
⊞ data table⬇ CSV
| Reported harm | Physicians reporting % |
|---|---|
| Delays in care | 94 |
| Care abandonment | 78 |
| Serious adverse event | 33 |
| Patient hospitalized | 25 |
| Permanent harm | 19 |
| Patient death | 7 |
AMA, 2023 Prior Authorization Physician Survey · 2023 · source
Weekly prior authorization requests per physician, by specialty
Reference line is the all-physician average of 45 requests per week. Specialty burden is highest where treatments are expensive and chronic.
Read it this way Compare each specialty's bar to the 45-per-week reference line: rheumatology (64) and oncology (58) carry far more prior-authorization volume than average, while dermatology (28) carries much less. The pattern tracks specialties with expensive, chronic treatments, but the chart doesn't show whether higher-volume specialties also face higher denial rates. Use this chart to see whether the authorization burden is volume, correctness, appeal friction, or harm, and how that evidence supports targeted reform rather than blanket approval or blanket denial.
⊞ data table⬇ CSV
| Specialty | Weekly PA requests per physician |
|---|---|
| Rheumatology | 64 |
| Oncology | 58 |
| Endocrinology | 53 |
| Cardiology | 47 |
| Gastroenterology | 44 |
| Primary care | 41 |
| Psychiatry | 36 |
| Dermatology | 28 |
AMA, 2023 Prior Authorization Physician Survey · 2023 · source
Why this matters
Two independent sources agree the denials themselves are often wrong. HHS OIG's stratified random-sample audit, not self-selected the way appeals are, found 13 percent of prior-authorization denials met Medicare's own coverage rules and 18 percent of payment denials should have been paid. Overturn rates on appeal vary sharply by service type: skilled-nursing-facility admissions are overturned 95 to 97 percent of the time, versus 43 percent for inpatient rehab and 36 percent for long-term care hospital stays, suggesting some service lines are denied far more aggressively than the evidence supports. The most common stated reasons, medical necessity (31 percent) and step therapy (22 percent), leave room for dispute, but missing documentation alone accounts for 13 percent of denials, a pure process failure with no clinical basis.
Recommended actions
- Require per-plan public reporting of denial and overturn rates by service type, so the SNF-level 95 to 97 percent overturn rate is visible to regulators and beneficiaries before they file an appeal.
- Extend gold-carding, exempting providers with historically low denial rates from prior authorization, to the service lines with the highest overturn rates first: skilled nursing, inpatient rehab, and long-term care hospital stays.
- Apply OIG's random-sample audit methodology plan-wide on a recurring basis, since self-selected appeals undercount how often initial denials are wrong.
- Target missing-documentation denials specifically with standardized submission templates, since this is a process fix with no clinical tradeoff.
- Track the appeal rate itself as a metric requiring intervention, since only 11.7 percent of denials were even challenged in 2023.
The recommendation
Therefore, reposition prior authorization as a targeted clinical-control tool rather than a default administrative hurdle. The recommended program is to require plan-level denial and overturn transparency, gold-card low-risk providers, standardize documentation, and audit service lines where overturned denials signal systematic overuse.
Demographic slice none. CMS prior-auth reporting and the AMA survey are payer or service-level.
Sources
- AMA, 2023 Prior Authorization Physician Survey · 2023
- KFF, Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023 · 2023
- HHS OIG, Some MAO Denials of Prior Authorization Requests Raise Concerns (OEI-09-18-00260) · 2022
- HHS OIG, MAOs Overturned Nearly All Appealed SNF Admission Denials (OEI-09-24-00331) · 2026
- KFF, MA insurers made nearly 53 million prior authorization determinations in 2024 · 2024