August 24, 2023
2:00 p.m. - 3:00 p.m. EST 

Prior authorization was originally developed to curtail expensive tests or care that was not needed in order for care to be more cost-effective. However, over time, insurers began requiring prior authorization for many common medical services. Now, the system creates administrative burdens, delays needed care, and increases patients’ cost burdens. Many patients do not have the time, willpower, or resources to fight denied claims—they give up and either go without the care or pay for it themselves out-of-pocket.

Reports have revealed that insurers flag expensive claims for special review and use computer programs to review, and often, deny, claims.¹ While data is limited, it shows that insurers deny between 10-20% of claims. Among Marketplace plans, 0.2% of denials were appealed, and of those, 41% were overturned;² among Medicare Advantage plans, 11% of denied claims were appealed, 82% were overturned.³

A few states have taken action to improve the process, including regulating the amount of time insurers are required to respond to prior authorization requests and requiring insurers to annually report data on the number of requests denied and appealed.^4,5

This webinar will explore the relationship between prior authorization and access to affordable health care for consumers, along with action states can take to improve the process.

The audience will include advocates, state officials, individuals working in service provision and community navigators.

• Kaye Pestaina, KFF
• Caitlin Donovan, National Patient Advocate Foundation
• Sebastian Arduengo, Vermont DFR

• Presentation Slides
• Recording 

Additional Resources:

• Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients (KFFHealth News)
• Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021 (KFF)
• Claims Denials and Appeals in ACA Marketplace Plans in 2021 (KFF)
• Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials (HHS OIG)
• Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care (HHS OIG)
• Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need (STAT)
• How Often Do Health Insurers Say No to Patients? No One Knows. (ProPublica)
• UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings. (ProPublica)
• How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them (ProPublica)
• Aetna reveals health care denial rates in Medicare Advantage court case for NYC retirees (Gothamist)
• Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care (JAMA Health Forum)
• Quantifying The Economic Burden Of Drug Utilization Management On Payers, Manufacturers, Physicians, And Patients (Health Affairs)
• Insurers Deny Medical Care for the Poor at High Rates, Report Says (The New York Times)
• Act No. 183 (2022) Report: Prior Authorizations; Administrative Cost Reduction (Vermont Department of Financial Regulation)

Time (minutes

Talking Points/Topics

Speaker

5

Welcome and introduction

Introduce speakers

Housekeeping

Elise

10-15

Prior Authorization Overview

Kaye Pestaina, KFF

10-15

Impact on Consumers

Caitlin Donovan, National Patient Advocate Foundation

10-15

What Can States Do? Vermont’s experience

Sebastian Arduengo, Vermont DFR

15

Elise moderates

2

Closing

Elise