Prior Authorization. Same Joke. Same Punchline.

When it comes to humor, I like repetition. The more you say something that’s funny, silly or goofy, the funnier, sillier or goofier it gets.

That’s why the latest report on prior authorization (PA) from KFF (formerly the Kaiser Family Foundation) made me laugh. It’s the same joke we’ve heard over and over and over again. Not the report itself, which is well done, but what the report says.

KFF researchers broke down Medicare PA data from the Centers for Medicare and Medicaid Services (CMS) all kinds of ways, only to find two things that we already know. Medicare Advantage (MA) plans operated by commercial health insurers demand more PA approvals than traditional Medicare. And MA plans and traditional Medicare ultimately approve most of their own PA requests.

I guess there’s a third thing we already know. PA is a huge waste of time and money.

Here are some of the report’s findings on MA plans’ PA behavior:

• MA plans made 52.8 million PA requests in 2024, a 6% increase from 49.8 million in 2023.
• That’s an average of 1.7 PA requests per MA enrollee in 2024, down slightly from 1.8 PA requests per enrollee in 2023.
• MA plans approved 92.3% of PA requests in 2024, down slightly from 93.6% in 2023.
• Of the PA denials appealed by patients or providers, MA plans overturned and approved 80.7% in 2024, down slightly from 81.7% in 2023.

By comparison, here are some of the report’s findings on traditional Medicare’s PA behavior:

• Traditional Medicare made 628,243 PA requests in 2024, a nearly 60% jump from 393,749 in 2023.
• That’s an average of 0.02 PA requests per traditional Medicare enrollee in 2024. The report did not provide a figure for 2023.
• Traditional Medicare approved 77.1% of PA requests in 2024, notably up from 71.2% in 2023.
• Of the PA denials appealed by patients or providers, traditional Medicare reversed and approved 28.7% in fiscal 2022, which ran from Oct. 1, 2021, through Sept. 30, 2022. That’s the latest data KFF had for its new report.

When you put it all together, MA makes more PA requests than traditional Medicare, but either way, both ultimately approve most of their own PA requests. Same joke. Same punchline. Again, and again.

Maybe repetition isn’t funny when the joke’s on consumers who are waiting for medically necessary care to make them healthy or keep them alive. Building a better healthcare system will require reforming or eliminating the PA process. It serves no one other than vested financial interests.

To learn more about this topic, please read, “Prior Authorization Is About Payments, Not Patients.”