ArticleBMJ (Clinical research ed.)2024
Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage.
Article in BMJ (Clinical research ed.), 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 21 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
21 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Artificial intelligence in prior authorization and coverage decisions: A systematic review of methods, evidence gaps, and future implications for patient access.Journal of managed care & specialty pharmacy · 2026Pooled it
- Health Care Utilization and Equity in Medicare Advantage Compared With Traditional Medicare.JAMA network open · 2026Article
- Variation in medical claim denials: safety-net providers are hardest hit.Health affairs scholar · 2026Article
- Prior Authorization Requirements in Medicare Advantage and County Social Vulnerability.The American journal of managed care · 2026Article
- Medicare Advantage Prior-Authorizations Are Linked to Racial Differences in End-of-Life Home Health Use.Journal of the American Geriatrics Society · 2026Article
- Timeliness of antiresorptive consolidation after anabolic therapy for primary fracture prevention: A US cohort study.The Journal of clinical endocrinology and metabolism · 2026Article
- Second-Level Appeals of Denied Anticancer Medication Claims in Medicare Part D.JAMA network open · 2026Article
- Health System Integration and Prior Authorization in Medicare Advantage.Health services research · 2026Article
- Medicare Insurance Type and Broad Genomic Profiling in Metastatic Cancer.JAMA network open · 2026Article
- State Medigap Policies and Disenrollment From Medicare Advantage Among Beneficiaries With Cancer.JCO oncology practice · 2026Article
- Risk Adjustment for Alzheimer Disease and Related Dementias in Medicare Advantage and Health Care Experiences.JAMA network open · 2026Article
- Trends in prescription drug coverage restrictions in Medicare, Medicaid, and commercial insurance plans, 2011-2019.Health affairs scholar · 2026Article
- Racial and Ethnic Disparities in Preventive and Chronic Disease Care in Medicare Advantage vs. Traditional Medicare.Journal of general internal medicine · 2026Article
- Integrating Prior Authorization Into Clinical Workflows for Care Access and Practitioner Experience.JAMA network open · 2025Article
- Medicare Advantage reimbursement structures impact home health delivery and outcomes.The American journal of managed care · 2025Article
- Prior Authorization, Quantity Limits, and Step Therapy for Patient-Administered Antiemetics.JAMA network open · 2025Article
- From Disappointment to Predominance: Medicare Advantage's Ascendancy and Transformation of Medicare.The Milbank quarterly · 2025Article
- Payment Source Shift for Surgical Care Among Veterans Enrolled in Medicare Advantage Plans.JAMA health forum · 2025Article
- Radiotherapy Utilization in Traditional Medicare and Medicare Advantage.JAMA network open · 2025Article
- Prior authorization and utilization management for post-acute home health in Medicare Advantage: the motivations, players, processes, unique challenges, and impacts on patient care.Health affairs scholar · 2025Article
Corrections and comments
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Authors and funding
4 authors.
Funding
Abstract
objectiveTo measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories.
designCross sectional analysis.
settingPA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.
participants30 540 086 beneficiaries in traditional Medicare Part B.
main outcome measuresProportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules.
resultsThe insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties.
conclusionPA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.
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