Prior Authorization Resources

Department of HHS Office of Inspector General

OIG identified denials of prior authorization requests for post-acute care after a hospital stay as a particular area of concern. This report shines new light on variation in denial and overturn rates of requests for admission to long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs), which provide therapeutic and rehabilitative care to patients after an illness or injury.

Medical Group Management Association (MGMA)

MGMA survey finds that prior authorization, Medicare Advantage requirements, and quality reporting are the most critical issues requiring practices to divert time and resources away from patient care and into administrative tasks.

Senate Judiciary Committee

The Senate Judiciary Committee released a majority report examining UnitedHealth Group's use of MA risk-adjustment practices that led to higher diagnosis coding and increased federal payments.

American Academy of Orthopaedic Surgeons (AAOS)

AAOS study finds prior authorization adds delays without saving costs for hip replacement patients.

Kaiser Family Foundation (KFF)

A KFF Health Tracking Poll revealed that most Americans find the prior authorization process burdensome.

Senate Homeland Security Committee

The Senate Homeland Security Committee released a report with findings about Medicare Advantage plans and prior authorization in post-acute care.

Medscape

Medscape published an infographic that presents findings from a new report about doctors' experiences with prior authorization.

Government Accountability Office (GAO)

GAO released a report that found states are not properly monitoring plans' prior authorization decisions.

Health Affairs

A study conducted which demonstrates that prior authorization affected an increasing share of prescription drugs.

Office of Inspector General (OIG)

OIG released an impact brief on Medicare Advantage prior authorization that highlights the impacts of OIG's oversight work.

Kaiser Family Foundation (KFF)

Evidence from KFF study on problems consumers have with prior authorization.

Office of Inspector General (OIG)

OIG conducted a study on whether MCOs were providing necessary services to their enrollees.

Medical Group Management Association (MGMA)

MGMA survey finds prior authorization is increasingly burdensome for medical group practices.

Office of Inspector General (OIG)

OIG developed a managed care strategic plan and designated managed care as a priority area.

Kaiser Family Foundation (KFF)

Over 35 million prior authorization requests were submitted to Medicare Advantage plans in 2021.

American Society of Clinical Oncology (ASCO)

Survey shows negative impact of prior authorization on cancer care.

Government Accountability Office (GAO)

New GAO study finds prior authorization less likely to be granted for mental health.

Medical Group Management Association (MGMA)

MGMA finds virtually all medical groups say payer prior authorization requirements aren't improving.

Congressional Research Service (CRS)

CRS provides information on the Seniors' Act and prior authorization use in Medicare Advantage.

Letter to Brooks-LaSure
January 5, 2024

Comment letter to the CMS Administrator on Contract Year 2025 Policy and Technical changes to the Medicare Advantage program proposed rule. This rule would make changes to Utilization Management committees and asks for comments about whether Medicare Advantage plans should have to make prior authorization equity analysis data available.

Letter to Brooks-LaSure
March 13, 2023

Comment letter to the CMS Administrator on the electronic prior authorization (e-PA) Proposed Rule. This proposed rule would significantly reduce barriers to care and lessen provider burden associated with payers prior authorization requirements.

Letter to Brooks-LaSure
February 13, 2023

Comment letter to the CMS Administrator on Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program proposed rule. This proposed rule would set landmark guardrails around the use and abuse of utilization management tools including prior authorization in the Medicare Advantage program.