Medicare Advantage plans denied 7.4 percent of medical professionals’ prior authorization requests, or about 3.4 million requests, according to a recent KFF analysis of 2022 data. With just 1 in 10 patients appealing these denials, prior authorization denial often means care is foregone.

For Kendra Sollars and her family, a Medicare Advantage plan’s prior authorization denial meant choosing between paying high out-of-pocket costs for skilled nursing services that her 77-year-old father’s physician prescribed or sending him home to finish his recovery without the proper care his condition required.

This choice is one that many families must wrestle with due to the high denial rates that have become the standard for Medicare Advantage plans.

From the article:

When Kendra Sollars received the letter, she was shocked.

In the preceding months, her father’s falls had quickly gone from an occasional scare to a far-too-often occurrence. G. M. Sollars, M.D., a former emergency medicine physician and self-declared Star Trek nerd, had spent weeks in the hospital and the skilled nursing facility where he lived when the letter came. He’d been diagnosed with radiation-related neuropathy following treatment for a recently diagnosed cancer. It was going to be a long recovery.

So as Kendra read the Notice of Medicare Non-Coverage from her dad’s Medicare Advantage plan, she was confused. Every physician she’d spoken with had told her that her 77-year-old father needed more time to recover before returning to his home near Scottsdale, Arizona. But the letter laid out the reality: “Medicare probably will not pay for your current skilled services after the effective date,” it read.

“He was getting kicked out and he couldn’t even walk,” Kendra said in a recent interview with JAMA Medical News. “It was either go home to absolutely nothing or pay out of pocket”—unless they could get a prior authorization approved.

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