Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures in 2021

• Published in: Otolaryngology-head and neck surgery Vol. 171; no. 5; pp. 1601 - 1604
• Main Authors: Miller, Lauren E., Miller, Ashley L., Rocco, James W., Rathi, Vinay K.
• Format: Journal Article
• Language: English
• Published: England 01.11.2024
• Subjects: denial; Fee-for-Service Plans; Humans; medical necessity; Medicare Advantage; Medicare Part B; Medicare Part C - legislation & jurisprudence; Otolaryngology - legislation & jurisprudence; Otorhinolaryngologic Surgical Procedures; prior authorization; Prior Authorization - legislation & jurisprudence; revenue cycle; United States; utilization management; United States; Medicare Part B; denial; revenue cycle; utilization management; Medicare Advantage; prior authorization; medical necessity
• ISSN: 0194-5998; 1097-6817
• DOI: 10.1002/ohn.931

Little is known about the extent of prior authorization requirements in otolaryngology. We performed a secondary analysis of data comparing prior authorization (PA) policies across 5 major Medicare Advantage insurers to estimate the counterfactual proportion of 2021 Medicare Part B fee‐for‐service spending and utilization for commonly performed otolaryngologic procedures that would have required PA. The counterfactual proportion of spending (range: 20.4%–27.6%) and utilization (range: 1.8%–4.5%) requiring PA was relatively consistent across insurers and largely attributable to rhinologic procedures. However, PA requirements for specific services varied widely among insurers. Among the 70 (of 196; 35.7%) services subject to PA by any insurer, nearly half were subject to PA by a single insurer (n = 34; 48.6%). Only 10 (14.3%) services were subject to PA by 4 (n = 6; 8.6%) or 5 (n = 4; 5.7%) insurers. These discrepancies illustrate the challenges of navigating discordant insurer policies for otolaryngologists and raise concerns about the validity of certain PA requirements.