Prior authorization metrics provide new insight, KFF says

WASHINGTON – Medicare Advantage insurers denied 13% of standard prior authorization requests, Medicaid managed care insurers denied 14% and ACA Marketplace insurers denied 18%, according to a new analysis from KFF.

Insurers were required to post the first year of prior authorization metrics for the 2025 calendar year by March 31, 2026. KFF collected and analyzed these metrics from the largest insurers in most market segments for which reporting is required.

Other key takeaways from the data:

• Prior authorization denials are rarely appealed, but when they are, a considerable share are overturned. Sixty-seven percent of prior authorization denials were overturned upon appeal in Medicare Advantage, 47% were overturned upon appeal in Medicaid managed care, and 43% were overturned in the ACA Marketplace.
• Median response times in all markets were about one day for standard prior authorization requests, and about half a day for expedited prior authorization requests for Medicare Advantage, and approximately one day for Medicaid managed care and the ACA Marketplace. Insurers are not required to report response time ranges or differences by service category. 
• Despite the regulatory intent to make insurer prior authorization practices more transparent, difficulty locating and interpreting metrics on insurer websites and gaps in how (e.g., a standardized template that insurers are required to use) and what metrics (e.g., denominators and breakouts by service category) must be reported limit the usability of this information directly by the public.

In 2024, the Centers for Medicare & Medicaid Services (CMS) published a final rule aimed at streamlining and automating the prior authorization process for almost all insurance programs it oversees: Medicare Advantage, Medicaid and CHIP fee-for-service and managed care plans and ACA Marketplaces. As part of these requirements, every year, payers in these programs are now required to publicly post on their websites specified prior authorization metrics, including approval and denial rates and response times, aggregated for all medical items and services (excluding prescription drugs) for the previous calendar year.

• Related: AAHomecare throws weight behind Medicare Advantage reform.