Insurers Denied Between 12% and 18% of Prior Authorization Requests in 2025 in the Medicare Advantage, Medicaid and ACA Markets, with Large Variations by Insurer

https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/?utm_medium=email&_hsenc=p2ANqtz-_1FDTYo0RPxhzXPT47gK_c6cKHkBuDSM5eGuoUQnm140VBNiy_ccxDQzxu8cevxkRMPSbC9PSteZDPKLawZC8JiMBE8w&_hsmi=433028420&utm_content=433028420&utm_source=hs_email Insurers Denied Between 12% and 18% of Prior Authorization Requests in 2025 in the Medicare Advantage, Medicaid and ACA Markets, with Large Variations by Insurer Gaps in Publicly Available Data on Prior Authorization Limit Usefulness for Consumers Insurers denied at least 1 in 8 standard requests for prior authorization in 2025 across three major markets – Medicare Advantage (12%), Medicaid managed care (14%), and the Affordable Care Act Marketplaces (18%), finds a new KFF analysis of publicly available data. In each market, denial rates were slightly lower for “expedited” requests for prior authorization – when a longer review process could seriously jeopardize a patient’s life, health, or recovery – though at least 1 in 10 of these more urgent requests were denied. Insurers require prior authorization for certain procedures and treatments as a way to reduce unnecessary care and contain costs. The practice has received increased attention in recent years as it can lead to delays or denials in receiving care and creates administrative burdens for patients and providers. KFF’s analysis examines data about insurers’ prior authorization use that plans are required to post publicly as part of a 2024 final rule from the Centers for Medicare and Medicaid Services aimed at streamlining and automating the prior authorization process. The analysis assessed data from 14 large insurers with the largest enrollment in each market. Prior authorization denial rates varied widely across insurers within each market. Among Medicare Advantage insurers, the denial rate for standard requests ranged from 5% for Elevance to 17% for United Health Group. In Medicaid Managed Care, the range went from 2% for L.A. Care Health Plan to 23% for Independence Health Group. In the ACA Marketplace, the range went from 3% for GuideWell to 25% for Centene. The available data only shows total denial rates, making it impossible to analyze denial rates for specific types of services such as MRIs and other imaging tests, post-acute care, or mental health care. Insurers also are only required to report their data in percentage terms, so it is hard to assess how often insurers require prior authorization relative to their claim volumes and to other insurers. Other findings include: When prior authorization denials are appealed, the original decision is often overturned across the three markets – two-thirds (67%) of the time in the Medicare Advantage market, nearly half (47%) of the time for Medicaid managed care, and 43% of the time in the ACA Marketplaces. Median response times in all markets were about one day for standard prior authorization requests. For expedited requests, the typical response time was half a day for Medicare Advantage and about a day for Medicaid managed care and the ACA Marketplace. The short median response times may stem from the growing use of artificial intelligence and electronic systems to help process requests. The analysis also highlights several limitations in the publicly reported data that reduce its usefulness for consumers. For example, insurers’ prior authorization data is often difficult to locate on their websites, and they are not required to present the data in a standard template, with the same details, making comparisons across insurers difficult. The analysis also reviews current regulatory requirements around prior authorization data reporting efforts at the federal and state level, as well as ongoing efforts to address the burden that they pose for consumers and providers.