More Than 80% of Prior Authorization Appeals Succeed, What’s Stopping Us from More?

The prior authorization process has become a cornerstone in the relationship between healthcare providers, insurers, and patients, aiming to control healthcare costs by requiring approvals for certain medical procedures, medications, and treatments. Despite the aim of cost control, many prior authorization denials directly impact patient care, often resulting in delays and, in some cases, significant patient harm.

Surprisingly, even with a high success rate for appeals—83.2% of which were either partially or fully overturned in 2022—only one in ten denied requests was appealed. This statistic begs the question: if most appeals are successful, why aren’t more prior authorization denials being challenged?

The High Success Rate of Prior Authorization Appeals

The KFF analysis based on CMS data between 2019 and 2022 reveals an undeniable trend: a large percentage of appealed prior authorization denials are successful. In 2022 alone, over 80% of appeals led to favorable outcomes for patients, mirroring trends from previous years. These figures clearly suggest that many denials are not a matter of medical necessity but rather issues within the prior authorization process itself. Despite this success rate, however, a staggering number of physicians and patients do not appeal, leaving patients without the necessary care and incurring additional burdens on the healthcare system.

Why Are Physicians and Patients Not Appealing?

The reluctance to appeal stems from a combination of logistical barriers, resource limitations, and emotional disincentives. A recent AMA survey offers valuable insights into why this gap exists.

1. Doubt in Appeal Success Rates

Survey Data: Sixty-two percent of physicians indicated they don’t believe appeals will succeed, likely influenced by previous unsuccessful attempts or distrust in the appeal system.

Impact: This belief dissuades both physicians and patients from initiating what can feel like a futile and time-consuming process, even when the odds of a successful appeal are high.

2. Time Constraints and Resource Limitations

Survey Findings: Forty-eight percent of physicians report that they lack the staff time or resources to file appeals. The AMA survey highlights that physicians and staff dedicate an average of 12 hours weekly to prior authorization requests, with 35% of physicians employing staff solely for handling these tasks.

Practice Testimonial: One Mississippi-based internist and addiction-medicine specialist noted how the logistical delays often force patients, who may live hours away, to abandon their care plans. Patients unable to make multiple trips due to work or family obligations are left without necessary treatments.

Patient Perspective: The time-intensive appeal process can be overwhelming, with many Medicare Advantage enrollees unaware of their right to appeal or too intimidated to engage in what they perceive as a complex, bureaucratic process.

3. Patient Harm and Delayed Access to Care

Adverse Effects on Health: A considerable number of physicians (94%) have reported that prior authorizations delay necessary care, with many citing serious adverse events, including hospitalizations, life-threatening conditions, and in severe cases, permanent impairment or even death.

Survey Data: A staggering 19% of physicians reported hospitalizations directly resulting from delays associated with prior authorization denials. An additional 13% reported life-threatening events or interventions to prevent permanent impairment, underscoring how significant these appeals can be for patient outcomes.

The American Medical Association’s Call for Reform

The AMA has been vocal about the need to reform prior authorization processes, advocating for transparency and efficiency improvements that could prevent unnecessary denials and streamline appeals. The association’s recommendations include:

• Gold-Carding Programs: A streamlined approach where healthcare providers with demonstrated success in prior authorization requests are permitted to bypass repeated approvals.
• Chronic Condition Continuity: Extending the validity of prior authorizations for chronic conditions to cover the entire treatment period, avoiding redundant requests.
• Transition Continuity: New health plans should honor previous payers' prior authorizations for at least 90 days to ensure continuity of care.
• Federal Legislation Support: The AMA supports the bipartisan Improving Seniors’ Timely Access to Care Act of 2024, which seeks to reform Medicare Advantage prior authorization procedures, aiming to improve response times and reduce administrative burdens on providers.

Addressing Systemic Challenges in Appeals

There is an urgent need for strategies that encourage appeals and mitigate the deterrents providers and patients currently face. Viable solutions include:

Reducing Administrative Burden: Automating parts of the prior authorization process could significantly reduce the hours dedicated to authorization requests, freeing up practice resources to pursue appeals.

Increased Patient Education: Educating patients about their right to appeal could empower more enrollees to initiate the appeal process, particularly in Medicare Advantage, where complexities often discourage action.

Insurer Accountability and Transparency: Insurers need to standardize the criteria required for prior authorization and make this information accessible to prevent delays and improve the initial approval rate.

In Conclusion

The high success rate for prior authorization appeals underscores the flaws in the current system, where too many denials are either unnecessary or incorrect. The costs of these denials—delayed care, patient harm, and lost practice resources—suggest that an overhaul of the prior authorization system is long overdue. By adopting reforms that align the process with patient needs, insurers can help ensure that access to medically necessary care is not obstructed by red tape, allowing both patients and providers to focus on what matters most: delivering and receiving timely, effective healthcare.

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