Results Show High Rates of Denial and Thousands of Days Spent Waiting For Prior Authorization
March 8 2022 – Today, the American Medical Rehabilitation Providers Association (AMRPA) released the results of its nationwide survey of rehabilitation hospitals and units, which examined barriers to care for Medicare Advantage (MA) beneficiaries in need of post-acute care. The survey supports the long-running frustrations of Medicare providers and their vulnerable patient populations who must navigate the prior authorization (PA) practices of MA plans.
The survey asked rehabilitation hospitals and units (referred to by Medicare as “IRFs”) to track their MA prior authorization requests for a single month (August 2021), when the Delta variant of COVID-19 was pushing many hospitals to the limits of their capacity. The vast majority of all patients seeking admission to an IRF are hospitalized at an acute-care hospital. Among the most striking findings of the survey, MA plans overruled more than 50% all physician recommendations, and hospitalized patients waited on average more than two and a half days for decisions from plans. The results of more than 12,000 authorization requests were included in the survey, and showed more than 30,000 total unnecessary days waiting during the month.
“The results of this survey demonstrates the pressing need for policy makers to take long-overdue steps to curb prior authorization practices and ensure Medicare beneficiaries receive the care they need and are entitled to,” said Anthony Cuzzola, chair of the AMRPA Board of Directors. “In my hospital and in those I speak to around the country, we see patients needlessly waiting for decisions and discharged to inappropriate settings due to prior authorization.”
These survey results were included in a response to a request for information from the Centers for Medicare and Medicaid Services (CMS) on how PA for post-acute placement impacted the response to the COVID-19 Public Health Emergency (PHE). In AMRPA’s response, the association detailed the concerning behaviors of MA plans when responding to PA requests for intensive post-acute care. The association also provided analysis of other data supporting the inappropriate restrictions placed on access to IRF care for MA beneficiaries.
“This survey provides valuable insight into the enormous costs borne by patients, hospitals and the government due to prior authorization,” said Chris Lee, Vice-Chair of the AMRPA Board of Directors. “The system is in need of serious reforms to ensure patients who need access to prompt rehabilitation care are not diverted due to financial or other non-medical considerations.”
The survey included results from 475 total IRFs around the country from 47 states, which is more than 40% of all IRFs nationwide. Additional information on the survey results in included in a fact sheet below. You can access a full report on the survey and AMRPA’s full response to the CMS RFI here.
About AMRPA
AMRPA is the only national voluntary trade association representing more than 700 inpatient rehabilitation hospitals and units (IRH/Us). AMRPA member hospitals provide rehabilitation services across multiple health care settings to help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement.
Fact Sheet: Nationwide Survey of Rehabilitation Hospitals Demonstrates Systematic Barriers and Delays Caused by Prior Authorization Practices
The American Medical Rehabilitation Providers Association (AMRPA) conducted a nationwide survey of rehabilitation hospitals to capture how prior authorization practices impact access to care for Medicare Advantage Beneficiaries. The survey asked rehabilitation hospitals and units (referred to by Medicare as “IRFs”) to track their experiences with prior authorization requests to Medicare Advantage (MA) plans for admission to their hospitals during the month of August 2021. The results demonstrate the harmful effects of prior authorization on patients’ access to timely care, as well as the additional costs and burdens faced by hospitals and the Medicare program.
Key Findings:
- On average, patients waited more than two and a half days for an initial response to a request for This resulted in more than 30,000 days waiting during the survey month. This includes more than 14,000 days just for approved patients. These additional acute-care hospitals days not only delay access to needed therapeutic interventions, but also are also unnecessary costs ultimately borne by the government and patients.
- The total denial rate was 53% for all requests, despite all of these patients being deemed appropriate for admission by the rehabilitation This translates to approximately 6,000 Medicare beneficiaries denied access to IRF care during the month of August.
- The denial rate and delays in access were uniform across the 87% of IRFs reported having 30% or more of their requests denied. 84% of IRFs said they waited on average more than 2 days for determinations.
- Providers reported that 39% of all requests required the hospital or patient to exert additional effort to attempt to admit the patient, such as physician to physician discussions, additional documentation requests, formal appeals, and other burdens. Of those cases in which the hospital or patient took additional steps to admit the patient due to their pressing need for IRF care, only 28.94% were ultimately approved for admission by the MA plan.
Background:
- The survey resulted in responses from 435 hospitals, which is 40% of all IRFs It included hospitals in 47 States and results of more than 12,000 requests for authorization. It was conducted during a surge of the Delta variant of COVID-19, when many hospitals struggled to maximize capacity.
- MA plans are required to provide the same benefits as traditional Medicare (including IRF care), as well as respond to requests as expeditiously as is required for patients’ Under the strict Medicare criteria for admission to an IRF, all patients must be screened and ultimately approved for admission by a specialized rehabilitation physician at the IRF. Despite meeting Medicare criteria, MA plans often overrule rehabilitation physicians and deny authorization for admission to an IRF using alternative criteria and unqualified reviewers.
- Most IRF patients are admitted from an acute-care hospital following a serious injury or However, hospitals report it frequently takes 3 or more days to receive a determination for patients which often leads to inappropriate discharges to other settings or unnecessary days in an acute-care hospital.
*Many hospitals also indicated some prior authorization requirements were waived during the survey period due to COVID-19. Therefore, the total wait days may actually be higher during more typical time periods.
** Hospitals also report they frequently withdrew authorization requests prior to a determination being reached because a patient no longer wanted to wait to be discharged, or other reasons. These withdrawn requests were not counted, and means the effective denial rate may be even higher than reported.
