When you are sick or in pain, the prior authorization process can be frustrating and will sometimes result in a denial. If you've never been through the process, prior authorization is a requirement that a health care provider obtain pre-approval from your insurer to provide a given service. This is true whether you are covered by Original Medicare or a Medicare Advantage Plan (MA). In 2023, Medicare Advantage insurers made nearly 50 million prior authorization determinations. As enrollments in MA plans have grown, the number of prior authorizations has steadily increased, according to a KKF study.
Original Medicare requires prior authorization for a substantially smaller set of procedures and services than most MA plans. Medicare services that typically require prior authorization include certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment. For 2023, just under 400,000 prior authorization reviews for traditional Medicare beneficiaries were submitted to CMS.
