Insurers Make Prior Authorization Data Available to Public

A new federal transparency requirement is making health plan prior authorization data publicly available for the first time—including for many Medicare Advantage (MA), Medicaid managed care, CHIP, and Affordable Care Act Marketplace plans. Insurers must now post standardized metrics such as prior authorization volume, approval and denial rates, average processing times, and appeal outcomes.

This transparency is a welcome step toward accountability, but the early reality is more complicated. According to a KFF report, the data are often difficult to find on plan websites, reported in inconsistent formats, and aggregated at a level too high to show what is happening to specific items and services. High approval rates on paper may also mask delays that effectively function as denials for patients with time-sensitive conditions.

Even with its shortcomings, the new reporting is a powerful advocacy tool that can help pinpoint outlier plans, substantiate clinician experiences with burdensome prior authorization, and press for stronger federal standards on timeliness, transparency, and clinically valid criteria, including streamlined—or waived—prior authorization for evidence-based care.

ACOI has endorsed legislation that would require MA plans to make their prior authorization data, including approvals and denials, available by service and item which would add much-needed transparency to current requirements. ACOI members are encouraged to contact their members of Congress through the ACOI Action Center and ask them to pass that legislation—the Improving Seniors’ Timely Access to Care Act—this year.