Change is Coming to Medicare Pre-Authorizations
After 65 years on this earth, I’ve learned that a lot of good ideas start with great intentions — and then morph into something far more complicated than anyone planned. Medicare pre-authorizations are a perfect example. They were created to make sure services were necessary, covered, and paid for. But over time, they’ve turned into one of the most frustrating parts of the healthcare system for seniors.
What a Pre-Authorization Actually Is
A pre-authorization is when your provider has to get approval from Medicare, Medicare Advantage, or another insurer before you can receive certain services. The goal is to control costs, prevent unnecessary care, coordinate treatment, and cut down on fraud and abuse. Medicare uses standardized codes — CPT and HCPCS — to identify which services require approval.
How Often They Happen
- Original Medicare (Part B): Rarely. Only 0.02% of services need approval.
- Medicare Supplemental Plans: Never. If Medicare pays, your supplemental plan pays.
- Medicare Advantage Plans: Frequently. About 27% of services require pre-authorization, so if you have an Advantage plan, you’ll probably encounter it sooner or later.
How the Process Works
With Original Medicare, providers send documentation to Medicare Administrative Contractors (MACs), who review it in 7 days for standard requests or 48 hours if it’s urgent. Supplemental plans don’t have any pre-authorization process at all.
Medicare Advantage plans require providers to send paperwork to the insurance company, and every company has its own process. They have up to 14 days for standard requests (soon to be 7) and 72 hours for urgent ones.
The Problems With Medicare Advantage Pre-Authorizations
The number of requests has exploded — from 36 million in 2019 to 50 million in 2023. Denial rates are up too, from 5.7% in 2019 to 7.4% in 2023. And here’s the kicker: over 80% of appeals are approved, but only 11% of people ever appeal. That means a lot of denials never get corrected.
Post-acute care, like skilled nursing and home health, gets hit the hardest — with 25% of requests denied. That’s a huge issue when you’re recovering from a hospital stay.
Why Original Medicare Handles It Differently
For post-acute care, Original Medicare doesn’t require pre-authorization at all. Your doctor decides how long you stay, not an insurance company. You can go to any Medicare-accepting provider nationwide, and care decisions are made by clinicians — not algorithms.
In contrast, 99% of Medicare Advantage plans require pre-authorization for post-acute care, often relying on AI tools like NH Predict to guide decisions.
Changes Coming to Original Medicare in 2026
From January 2026 to December 2031, the WISER model will pilot in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It will add pre-authorization for 17 new services, including nerve stimulators, spinal surgeries, and wound care. Providers can request reviews before or after service — but prepayment reviews risk delayed or denied payments if paperwork isn’t perfect.
Changes Coming to Medicare Advantage Plans
Some of these updates are positive:
- Public reporting of approval and denial rates
- Fewer services requiring pre-authorization (some aiming for a 33% cut)
- Electronic submissions starting January 2026 to speed things up
- Faster decisions — 7 days for standard requests, 72 hours for urgent ones
- By 2027, 80% of requests expected to be processed in real time
- 90-day carryover of pre-authorizations when you switch plans
- Clinician-led reviews for denials instead of relying solely on AI
Why Post-Acute Care Is Such a Target
It’s expensive. Skilled nursing can run $500–$560 a day, and the average stay is 37 days. Medicare Advantage plans have a financial incentive to limit these stays or push patients toward lower-cost home care. Some carriers have drastically increased denial rates — one went from 1.4% in 2019 to 12.6% in 2022.
Bottom line: If you have Original Medicare, you’ll rarely deal with pre-authorizations. If you have Medicare Advantage, it’s a routine part of care — but it’s also an area where big changes are coming. Knowing the rules and your rights can make the difference between getting timely care and waiting weeks for a green light.
