Health insurance companies frequently use prior authorization to control costs, requiring approval for various medical procedures, tests, and prescriptions. While denials are common, many are overturned on appeal. For instance, data from KFF shows that nearly 82% of Medicare Advantage prior authorization denials from 2019 to 2023 were partially or fully reversed after an appeal. Despite this, roughly half of insured adults find the appeals process difficult, a challenge that some suggest is intentionally designed by insurers to discourage persistence.
When facing a denial, it's crucial to act quickly as most health plans allow only six months to appeal, according to the Affordable Care Act. The process often begins by collaborating with your medical provider, who can initiate a "peer-to-peer" review with a medical professional from the insurance company. Keeping detailed records of all communications and documents, such as denial letters, medical records, and a letter of medical necessity from your doctor, is essential for a successful appeal.
If you receive insurance through an employer, your HR department can be a valuable resource, especially if your plan is self-funded, as your employer bears the cost of your care. Additionally, many states offer free consumer assistance programs that provide support in filing appeals and understanding benefits. While internal appeals are the first step, if denied, an external review by an independent third party is an option. Data from AuthDenied suggests that across reporting plans, an average of 52.8% of appealed denials are reversed, though this figure varies widely among plans.
