Insurers’ Prior Authorization Data Offers Little Insight Into What Gets Approved or Denied

Kaye Pestaina

For many Americans, especially those with a chronic condition, prior authorization requirements can delay and limit access to needed care. KFF found that four out of 10 insured adults with a chronic condition say prior authorization is their single biggest health care burden beyond costs. While the vast majority of prior authorization requests are approved, the process can still be burdensome for patients and physicians and result in delays in care and wrongful denials. A 2024 federal regulation requires certain insurers to publicly report specific prior authorization metrics, such as the overall average rate of denials, on their websites annually, with the first set of data covering 2025 posted by March 31, 2026. A first look at the new data reveals its limitations. 

An initial barrier is locating the required prior authorization reporting on insurers’ websites.  There is no consistent way to locate where on an insurer’s website this information is posted. Some insurers aggregate all of the reporting within a given line of business, while others require navigation to multiple pages to obtain the same information.

Insurers must report the percentage of certain prior authorization requests approved and denied, both for initial review and for appeals. UnitedHealthcare (UHC), a large insurer in Medicaid managed care, Medicare Advantage, and federal ACA Marketplace, reported on its website fairly high prior authorization approval rates, with some variation across its market segments. For example, UHC reported approval rates of about 80% in its HealthCare.gov plans, nearly 92% in Medicaid/CHIP, and 95% in Medicare Advantage. (KFF is currently reviewing data for all insurers.)

Because the information is aggregated across all items and services (except prescription drugs), with no breakdown about what types of services are being approved and denied, these statistics provide limited insight into insurers’ prior authorization practices. Insurers are not required to report the reason(s) a request was denied, and there is no way to assess whether the denial was appropriate under a patient’s insurance. In addition, high approval rates raise the question of whether an item or service should require prior approval to begin with.

The absence of prior authorization data for prescription drugs is also a limiting factor, given the current administration’s focus on making prescription medications more affordable. While the release of a CMS proposal for drug reporting could be imminent, this won’t directly help patients who face delays in accessing a covered medication due to administrative red tape.

Some states, including  Washington and Massachusetts, provide more detailed analysis of prior authorization, such as prior authorization metrics by service category and inclusion of prescription drugs, and could serve as models for more useful data collection.