When insurance companies do not agree with your doctor

Medicare Advantage is frequently in the news over Prior Authorizations. What does that mean? If you have government Medicare and a Medicare Supplement plan, when your doctor orders a surgery, you just schedule that surgery. There is no extra process to get approval from the insurance company for your treatment.

But with private Medicare, known as Medicare Advantage, when your doctor orders that same surgery, your doctor then has to ask the insurance company for PERMISSION to get that surgery. That is called Prior Authorization. Insurance companies can use this to delay or deny your treatment. Insurance companies have been sued for denying or delaying prior authorizations. There have been so many complaints to Medicare about this practice that the government has finally stepped in with new rules to speed up this process.

Medicare Advantage companies all have this issue. It’s not limited to one or two insurance companies. They defend the practice saying that they need to prevent unnecessary treatments by doctors who want to beef up their bank accounts.

This will be great news for the nearly 30 million people on Medicare Advantage. The new rules will require the insurance companies to respond to your doctor’s request within seven calendar days, and if it is an URGENT request, the insurance company must respond within 72 hours.

But this new rule doesn’t make the insurance company actually approve the medical care your doctor orders. The new rule just says that the insurance company must tell you sooner if it will deny or approve your procedure. It will also have to give a reason why it denies a procedure. By requiring insurance companies to give some type of medical explanation, they can be called out when they have no reason to deny procedures. This will be a win for Medicare Advantage members starting in 2026. This new rule doesn’t begin for another year.

If you get your prior authorization denied, either now or in the future, be sure to appeal. Most people fail to appeal the denial. But for those who do appeal, the rate of approval is very high. This process takes time. Be warned that it is as frustrating for your doctor’s office as it is for you. Providers spend countless hours faxing (yes, the insurance company wants a fax) requests for approval.

Clearly there is a more efficient way to process Prior Authorization requests. You can guess why they use such a slow process. Delays save money and private Medicare plans are about profits. This is not to say that I don’t recommend these types of plans. Just know that Prior Authorization is an extra hurdle you may face with Medicare Advantage – one you won’t face with government Medicare and a Medicare Supplement plan.

Sylvia Gordon is known as Medicare Mama on social media. She and the Noblesville-based TheMedicareFamily.com have amassed nearly one million followers online where she teaches about Medicare, Social Security, and retirement.