March 6, 2025 | Insurance Disputes

Imagine having your new insurer deny payment for a treatment or medication that you have been receiving? Many patients are experiencing this under the new Medicare Advantage plans. Many patients are finding that their insurers now require pre-authorization even for treatment they have been receiving for years. Why? Below, we discuss the difference between Medicare Advantage and traditional Medicare as well as why insurance companies are denying prior authorization.

What is Prior Authorization?

Before getting into the nitty-gritty of the current Medicare Advantage state of affairs, it is important to understand what prior authorization is and how it impacts insurance claims. Prior authorization, also referred to as pre-authorization, is the process used by insurance companies to determine the necessity of a medical treatment before it begins. Insurance companies may also require pre-authorization for life-saving surgeries as well as prescription medication.

Pre-Authorization and Medicare Advantage Plans

Many patients are surprised to discover that the coverage rules on traditional Medicare are different from those under Medicare Advantage Plans. Unlike traditional Medicare, Medicare Advantage insurance providers require prior authorization. Medicare Advantage plans are administered by private insurers. These plans are designed to provide the same benefits as traditional Medicare. However, they provide some additional benefits while still allowing patients to save on out-of-pocket expenses.

The drawback with Medicare Advantage plans is that private insurance providers operate like any other private business. They prioritize cost-cutting measures and seek out ways to save money. A recent report by the Office of Inspector General found that some Medicare Advantage insurers denied prior authorizations for medically necessary care even when the services met Medicare coverage rules.

In addition to denials, insurance providers also make it difficult for patients to appeal the denial. The claims processes are often complex. They are designed to frustrate patients and discourage them from challenging denials. Many patients therefore give up as they are unable to navigate the red tape.

Common Reasons Insurance Companies Give for Denying Pre-Authorizations

Medicare Advantage insurance providers have been known to provide a variety of reasons to justify pre-authorization denials. These include:

• The treatment is not medically necessary

The insurance company may claim that the procedure or medication to be provided is not essential. They may do this against the doctor’s recommendation and based on their own internal guidelines.

• There is a less expensive alternative

If the procedure or medication is deemed medically necessary, the insurance provider may deny pre-authorization citing that there are cheaper treatments or medications. This is even when these cheaper alternatives are less effective or appropriate for the patient’s condition.

• The healthcare provider is out of network

This is a common issue especially when specialists are involved. The insurer may refuse authorization if the healthcare provider is not within the plan’s preferred network.

• The treatment is experimental or investigational

Some insurers may refuse to cover newer treatments. This is even if they are approved by the FDA and backed by scientific research.

• More information is needed

It is common for insurance providers to resort to delay tactics. This includes requesting additional paperwork or medical records. This can slow down the process significantly and some patients give up.

• The procedure is not covered under the plan

Even though Medicare traditionally covers many treatments, Medicare Advantage plans have different rules and may not cover everything that traditional Medicare did.

What Can You Do?

If your insurance provider has denied a pre-authorization for a necessary medical treatment under a Medicare Advantage plan, don’t give up. There are steps you can take to access the medical care you need.

• Speak to an experienced attorney

It is important to make sure that you understand your rights and the legal options available to you. The best thing you can do for your case is to contact an experienced attorney and consult with them over the matter. At High and Younes Attorneys, LLC, we provide free initial consultation for patients pursuing health insurance claims. We’d be glad to review your case and guide you on the best approach to take.

• Appeal the denial

You can appeal the denial and have your claim reviewed. An experienced attorney can help with this. They can handle all communication and paperwork involved.

• Seek alternatives

An experienced attorney can also help you explore alternatives to ensure that you access the care you need. For example, if you’re seeking treatment for an injury that occurred as a result of an accident that was caused by another party, they can help you pursue a personal injury claim against the at-fault party.

Pre-authorization denial is not the end. You can fight to access the care you need. We at High & Younes, LLC are committed to fighting on behalf of patients seeking care. We’ll work to ensure your health and peace of mind.

Denied a Pre-Authorization