CONNECTED RCM · REGULATORY INTELLIGENCE BRIEF
Medicare Advantage Prior Authorization
By the Numbers
By the Numbers
The Trump administration’s June 2025 decision not to enforce MA prior authorization transparency requirements under CMS-0057-F — against a backdrop of 53 million annual PA requests, a 7.7% denial rate, and an 80.7% appeal overturn rate — raises critical questions for RCM teams about payer accountability and denial prevention strategy.
CMS-0057-F · JAN 2024
ROLLBACK · JUN 2025
SOURCE: KFF · AMA · CMS
01 · SCALE OF THE PROBLEM — MA PRIOR AUTHORIZATION 2024
53M
Prior Auth Requests
Submitted in 2024
Submitted in 2024
KFF 2026
4.1M
Requests Denied or
Partially Denied
Partially Denied
KFF 2026
7.7%
Overall MA Denial
Rate in 2024
Rate in 2024
KFF 2026
1.7x
Avg PA Requests per
MA Beneficiary/Year
MA Beneficiary/Year
KFF 2026
02 · DENIAL RATE TREND — 2019 TO 2024
MA Prior Authorization Denial Rate (% of all requests denied or partially denied)
Source: KFF Medicare Advantage Prior Authorization Analysis, 2019–2024
03 · APPEALS — A SYSTEM THAT REVERSES ITSELF
Denied Requests Appealed
11.5%
Only 11.5% of denied PA requests were appealed in 2024 — up from 7.5% in 2019, but still a small fraction of total denials. The majority of patients absorb the denial without contest.
KFF 2026
Appeals Fully or Partially Overturned
80.7%
Of the appeals that were filed, 80.7% were fully or partially overturned in 2024 — consistent across all years examined. Care that was denied was ultimately deemed necessary.
KFF 2026
RCM IMPLICATION
An 80.7% overturn rate on appealed denials signals that initial denials are frequently inaccurate. For every 100 denials, roughly 9 are appealed — and 7 of those are overturned. The other 91 likely go unchallenged, representing recoverable revenue absorbed as write-offs.
04 · DENIAL RATES BY MAJOR MA INSURER — 2024
Prior authorization denial rate as % of all PA requests, by insurer (2024)
UnitedHealth
12.8%
Aetna (CVS Health)
11.9%
Centene
12.3%
Kaiser Permanente
10.9%
Humana
5.8%
Elevance (Anthem)
4.2%
National MA average: 7.7% · Traditional Medicare denial rate: 22.5%
Source: KFF Medicare Advantage Prior Authorization Analysis, 2024
05 · PROVIDER BURDEN — AMA 2024 PHYSICIAN SURVEY
39
PA Requests per
Physician per Week
Physician per Week
13 hrs
Staff Time Spent on
PA per Week
PA per Week
40%
Practices with Staff
Exclusively on PA
Exclusively on PA
89%
Physicians Reporting
PA Increases Burnout
PA Increases Burnout
06 · WHAT THE TRANSPARENCY ROLLBACK REMOVED
What CMS-0057-F Required
✓ Public reporting of PA denial & approval rates annually (eff. Mar 31, 2026)
✓ Health equity expertise required on MA UM committees
✓ Plan-level health equity analysis reporting denial disparities by dual eligibility, income, and disability status
✓ PA response within 72 hrs (urgent) / 7 days (standard)
✓ Prior Auth API implementation by Jan 1, 2027
What the Jun 2025 Rollback Removed
✗ Health equity expertise requirement on UM committees — not enforced
✗ Plan-level health equity analysis of disparate denial rates — not enforced
✗ Visibility into denial disparities for dual eligibles, low-income, and disabled enrollees — eliminated
→ Remaining provisions (API, response times, public metrics) still in effect for now
→ First public PA metrics reports (CY2025 data) due Mar 31, 2026
KEY CONTEXT · Dually eligible beneficiaries — those enrolled in both Medicare and Medicaid — face denial rates up to twice as high as non-dual MA enrollees, despite having fewer average PA requests. The rolled-back health equity analysis would have been the primary mechanism to surface and correct this disparity. Its removal eliminates the accountability structure that would have required plans to identify and address it.
RCM STRATEGIC IMPLICATIONS
What This Means for Denial Prevention Operations
No Payer Accountability
Without health equity reporting, high-denial payers face no external pressure to justify disparate denial patterns. Denial prevention teams cannot benchmark plan behavior against disclosed data.
Dual Eligible Exposure
FQHCs carry a high proportion of dual-eligible patients — the population most affected by the rolled-back protections. Monitor denial rates for this cohort separately from your general MA population.
Appeal Everything
An 80.7% overturn rate means most appeals succeed. With reduced transparency, systematic appeal of all PA denials is more important than ever as a revenue recovery mechanism.
PUBLISHED BY
Connected RCM
SOURCES
KFF — Medicare Advantage Prior Authorization Analysis 2024 (Jan. 2026) · AMA Physician Survey on Prior Authorization (2024) · Georgetown CHIR — CMS Suspends MA PA Transparency Rules (Jun. 2025) · CMS-0057-F (Jan. 2024) · CMS Prior Authorization API FAQ · AMRPA MA Prior Authorization Survey (2024)
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