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This analysis of available 2025 prior authorization data finds insurers denied at least 1 in 8 standard requests for prior authorization across three insurance markets: Medicare Advantage, Medicaid managed care, and the federally facilitated ACA Marketplaces. Denial rates varied wide segments by insurer. The analysis highlights limitations of the data and challenges for consumers interpreting it.
Two recent reports find that Medicare Advantage organizations deny prior authorization requests for long-term care hospital, inpatient rehabilitation hospital, and skilled nursing facility stays at higher rates than requests overall. When these decisions are appealed, they are frequently overturned, particularly for skilled nursing facility stays. This may cause delays for Medicare beneficiaries who are particularly vulnerable or have high care needs.
This brief provides information about Medicare Advantage plans in 2026, including premiums, out-of-pocket limits, supplemental benefits, and prior authorization, as well as trends over time.
Amid the growing use of artificial intelligence (AI) in the claims review cycle, this brief discusses the types of consumer protections for use of AI in prior authorization and claims review, describes the Trump administration’s general approach to AI , and highlights areas to watch as Congress considers AI legislation.
Asked for a one-pager on what's wrong with the U.S. health system, Dr. Drew Altman, Founding President and CEO, explains the top issues in this piece, published today as his latest column. Altman explains, "We have neither a competitive health care system nor a regulated one—we have a fragmented, micromanaged health system that fails to control costs and makes both patients and health professionals more miserable than they should be..."
In this JAMA Health Forum column, KFF's Larry Levitt examines the criticism that health insurance companies are facing from political leaders, and explores the industry's role in both causing and addressing some of the health systems' biggest problems, including rising costs and prior authorization review.
Certain insurers must now publicly report specific prior authorization metrics, but the new data offer limited insight, providing no information on what types of services are being approved and denied or why as well as no data on prescription drugs.
In a new column, President and CEO Dr. Drew Altman writes about the "conundrum of health policy ideas" facing Democrats searching for new proposals because of competing, and complex, priorities: rebuilding Medicaid and the ACA after trillion-dollar cuts, reconstructing federal health agencies, and tackling underlying health care costs, when candidates want simple ideas they can campaign on and voters want their costs to come down.
This brief analyzes federal transparency data published by CMS on claims denials and appeals for Marketplace plan offered on HealthCare.gov in 2024, and finds insurers denied 19% of in-network claims. Consumers rarely appeal denied claims.
Our updated explainer provides an overview of comprehensive managed care, the most common way states deliver Medicaid services to enrollees.
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