Providers say Medicare Advantage prior authorization causes delays, rural strains
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Summary
Health system and physician witnesses told a House Ways and Means hearing that Medicare Advantage prior authorization volumes and denials are creating administrative burdens, delayed discharges and longer hospital stays, especially in rural areas.
Provider witnesses at the joint House hearing described growing operational strain from Medicare Advantage utilization-management practices and called for streamlined, electronic prior authorization processes.
David Basil, vice president of clinical quality for Avera Health, told the committee that his rural health system has seen a sharp rise in denials and authorization delays. “Our volume of care denials have more than doubled since 2022,” Basil said, adding that overturned denials and lengthy appeals processes impose large administrative workloads on facilities with limited staff.
Why it matters: Witnesses said prior-authorization delays can increase hospital length of stay, block timely discharge to post-acute care and leave hospitals holding higher costs. Basil described instances where MA plans downgraded inpatient stays to observation or refused payment for readmissions within 30 days even when unrelated to the initial admission.
Alignment Health Plan CEO Dawn Maroney said her company keeps prior-authorization denials below 2% by front-loading care coordination. “Approximately 95 to 97% of prior auths that come through the system are automatically approved at Alignment,” she said, describing care-navigator programs and early engagement for newly enrolled beneficiaries.
Witnesses from provider-sponsored plans and hospitals proposed a set of operational reforms: real-time electronic submission of clinical data from the electronic health record (EHR), clear point-of-care visibility into plan medical criteria, automating approvals for routine requests, and expanding tools that let clinicians submit complete documentation at the time of care. Johns Hopkins physician and testimony author Brian Miller urged “1-click submission of data in the electronic health record” and said automated approvals should be the default for well-documented, routine requests.
Several members highlighted rural impacts. Rep. Terri Sewell and others said small hospitals and rural clinics lack dedicated authorization teams and often must reassign clinical staff to appeals — work that detracts from patient care. Dr. Basil said extended waits for post-acute approvals can leave patients in acute beds and hamper transfers from rural hospitals to tertiary centers.
The committee discussed voluntary and regulatory steps to reduce burdens, including CMS and industry prior-authorization initiatives. Panelists differed on the role of AI: some witnesses argued it could speed approvals when programmed to approve routine requests, while others warned that AI trained on denial-first criteria could worsen access if left unchecked.
What’s next: Members asked for plan-level data on denial rates, overturn rates and average time to determination. Rep. Jan Schakowsky and others urged incorporating prior-authorization performance metrics into the public quality framework so beneficiaries and providers can compare plans. No formal rule changes were adopted at the hearing.