Prior authorization inpatient claim denial rate by payer type

Kodiak Solutions said in a May 21 report that if payers used consistent criteria for making prior authorization/preficiation claim denials, the denial rates would be similar across all payer categories. 

"That would make it easier for providers to learn from those denials, reduce their overall initial denial rates and spend fewer resources appealing prior auth/precert denials because of conflicting and ever-changing payment criteria," the report said 

Kodiak analyzed prior authorization inpatient claims denials over the past three years and found rates varied by payer category. The company's revenue cycle analytics software monitors patient financial transactions from more than 1,850 hospitals and 250,000 physicians nationwide.

"Assuming that patients’ medical conditions and severity of illness are generally the same across payer types and that providers generally diagnose and treat them the same way, the data suggests that payers are using different criteria to make prior auth/precert claims determinations," the report said. 

Here are the prior authorization and personification inpatient claim denial rate by payer category: 

Medicaid managed care 

2021: 4.25%

2022: 4.40%

2023: 4.17%

Traditional Medicaid

2021: 2.79% 

2022: 2.36%

2023: 3.16%

Medicare Advantage

2021: 2.36%

2022: 2.95%

2023: 2.69%


2021: 1.71%

2022: 2.23%

2023: 2.25%

Traditional Medicare 

2021: 0.09%

2022: 0.16%

2023: 0.16%

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Whitepapers

Featured Webinars