Did They Pay?

Category: Insurance Company Investigations

Evidence-based investigations of private insurers, third-party administrators, claims processors, denial practices, payment problems, regulatory actions, and payer accountability.

  • Medicare Advantage Prior Authorization Denials: What the 2024 Numbers Really Show

    Medicare Advantage insurers denied millions of prior authorization requests in 2024, but a denial count alone cannot tell whether a particular patient was treated fairly. The important questions are what was requested, why coverage was refused, whether the decision was appealed, and what happened afterward. Public statistics identify patterns; clinical records test individual decisions.

    What do the national numbers show?

    KFF’s January 2026 analysis of federal data found nearly 53 million Medicare Advantage prior authorization determinations in 2024. Insurers denied about 4.1 million, or 7.7%, in whole or in part. These are authorization requests, not necessarily unique patients. One patient may need approval for several services, and a denied request does not automatically mean care was never provided.

    Only 11.5% of denied requests were appealed. Among appealed denials, 80.7% were overturned. The high reversal rate deserves scrutiny, but it does not mean 80.7% of all initial denials were improper: the appealed cases are a selected subset, and some approvals follow submission of additional records. It does demonstrate why an initial denial should not automatically end the process.

    What the statistics cannot prove

    Insurers’ authorization rates depend partly on which services require approval, the clinical needs of enrollees, and how requests are recorded. A parent insurance company may operate several Medicare Advantage contracts, and its individual plans may have different rules. An insurer-wide rate cannot establish the correctness of a particular plan’s decision.

    A meaningful investigation identifies the plan contract, requested service, clinical criteria, denial rationale, records submitted, appeal outcome, and actual treatment delay. Comparing unlike service categories can mislead. Researchers should also distinguish an initial request denied for missing information from a determination that a complete request failed medical-necessity criteria.

    How to examine an individual denial

    Patients should request the written determination, service codes, specific clinical criterion, and any explanation of missing records. Providers should compare the decision with the clinician’s order, examination findings, diagnostic tests, treatment history, and plan criteria effective on the decision date.

    Build a dated record of submission, confirmation, information requests, initial decision, peer-to-peer discussion, appeal, and revised determination. Record whether treatment occurred and when. Do not label a medical complication as caused by the insurer without competent evidence. An accurate chronology is more useful than a broad accusation.

    What changed under federal rules in 2026?

    CMS’s 2024 interoperability and prior authorization final rule established, beginning in 2026, seven-calendar-day limits for standard medical-service authorization decisions and 72-hour limits for expedited decisions for certain impacted payers, including Medicare Advantage organizations. Decisions must be sooner when medical circumstances require it. The rules exclude drugs and do not impose the same new timeline on every commercial plan.

    CMS also requires impacted payers to provide specific reasons for prior authorization denials. Do not apply these 2026 provisions retroactively to 2024 cases. For current requests, verify the precise coverage program and service before asserting a legal deadline.

    A practical investigation checklist

    Identify the plan and requested service; obtain the dated determination and actual criteria; preserve submission receipts; compare clinical documentation with the stated reason; verify the appeal route and deadline; and record the ultimate outcome. Keep patient-facing explanations separate from internal coding shorthand.

    A useful appeal opening is: ‘The plan denied [service] on [date] because [reason]. Enclosed records address that criterion by documenting [facts]. Please identify any remaining requirement that is not met and provide a written reconsideration.’ The treating clinician should review clinical assertions before submission.

    Frequently asked questions

    Does an 80.7% reversal rate mean most denials are illegal? No. It measures reversals among appealed denials, not all denials, and says nothing definitive about the legal merits of an individual decision.

    Can a provider appeal? Often, with the appropriate authorization and plan-specific procedures. For help preparing a focused appeal, see our evidence-based appeals guide.

    Sources and further reading

    KFF: Medicare Advantage prior authorization data

    CMS: Improving Prior Authorization Processes

    CMS: Final Rule announcement

  • How Can You Investigate an Insurer’s Repeated Requests for the Same Records?

    Repeated requests for the same medical records do not by themselves prove misconduct. They do justify a documented investigation. Identify precisely what was requested, when it was transmitted, whether the payer acknowledged receipt, and whether the request concerns a different claim or service. Patients and billing teams should seek a written explanation before assuming a pattern.

    Separate a repeated request from a new request

    Compare the patient identifier, claim number, service date, requested pages, authorization number and receiving department. A request for a different date of service may look identical but concern a separate determination. Conversely, a payer may ask for documents already received because its intake and review systems do not communicate. Neither explanation should be accepted without checking the record.

    Build a transmission record

    Save the original request, submission cover sheet, portal confirmation, fax delivery record, secure message acknowledgment and any claim-status correspondence. Record the time, destination, document count and tracking reference. A successful fax transmission shows delivery to a destination, not necessarily that the correct reviewer associated it with the claim. Ask the payer to confirm indexing, not merely arrival.

    Ask questions that can be answered

    Request the exact missing document names and date ranges, the department holding the claim, the date documents were indexed, and the applicable review deadline. Ask whether a formal denial has been issued and whether appeal rights are running. For a provider, distinguish a medical-record request during claim adjudication from an audit, postpayment review or prior authorization request.

    Escalate without losing the claim

    If the payer cannot locate records, ask for a secure resubmission route and written confirmation of receipt. Preserve the earlier proof and submit again only through approved privacy-protective channels. Request a supervisor or provider-relations case number. If a denial has been issued, follow the applicable appeal process rather than waiting indefinitely for informal correction.

    What would establish a wider pattern?

    One frustrating claim is not a statistically valid investigation. Compare multiple independently documented claims with comparable circumstances. Track how often requests repeat, whether the payer acknowledges prior receipt, whether deadlines expire and whether claims are paid after escalation. Avoid publishing identifiable patient information or asserting intentional obstruction without evidence.

    A practical request script

    “For claim [number] and service date [date], we submitted the requested records on [date] with confirmation [reference]. Please identify each document still missing, confirm whether the earlier submission was indexed, state the current claim status and provide the correct written appeal or escalation route.”

    Frequently asked questions

    Does a delivery receipt prove the insurer reviewed the file? No. It supports transmission, not substantive review. Should I keep calling? Calls can help, but follow up in writing and record names, dates and reference numbers. Does a repeated request stop an appeal deadline? Do not assume so; check the governing notice and plan rules.

    Further guidance

    For a related practical explanation, see this Did They Pay? guide. For official guidance, consult the relevant government resource. Rules and deadlines vary by plan and program; always follow the actual notice governing your case.

  • How Can You Investigate an Insurer’s Repeated Requests for Records Without Assuming Bad Faith?

    Repeated requests for the same medical records may signal a transmission failure, an indexing problem, a mismatch between the requested dates and the records supplied, or an avoidable administrative delay. Investigate the actual document trail before concluding that an insurer is deliberately obstructing payment. Patients and providers can demand precise written explanations and preserve evidence for an appeal or regulatory complaint.

    Start with a document inventory

    Write down the claim number, member identifier, service dates, requesting department, document type, and each request date. Distinguish a request for the complete chart from one for a particular progress note, operative report, laboratory result, or authorization. An insurer might legitimately need a different document after reviewing an initial submission. The problem becomes clearer when the same specific record is requested after confirmed receipt.

    For every transmission, record the sender, destination, method, time, fax confirmation or portal receipt, attachment names, and any tracking number. Ask the practice to retain its submission confirmation. A fax confirmation establishes that a transmission occurred; it does not necessarily establish that the insurer indexed the attachment to the correct claim.

    Ask the insurer a question it can answer

    Instead of asking why it keeps losing records, ask which document remains outstanding, what dates it must cover, which claim or authorization record should receive it, and whether previously submitted documents are visible to the reviewing unit. Request a written response or a reference number for the call.

    If a representative says the file is complete, ask whether a clinical reviewer has actually received it and when a decision is expected. If the representative cannot answer, request escalation to the claims or utilization-management team with access to the record. Do not assume the call-center screen and the clinical review queue show identical information.

    Separate administrative delay from an appealable denial

    A request for information is not necessarily a final adverse benefit determination. Check whether the insurer has issued a formal denial, suspended the claim, or requested additional documentation under a stated policy. The distinction matters because appeal deadlines may run from a written determination, while claim-submission and response deadlines can be different.

    For many non-grandfathered private plans, federal rules provide internal appeals and qualifying external review. The exact procedure depends on plan type and governing law. See the federal appeals guidance and external review explanation. Medicare, Medicaid, and self-funded employer plans can have different channels.

    Escalate with evidence, not accusations

    Prepare a one-page chronology showing requests, submissions, receipt confirmations, and follow-up responses. Attach the actual denial or pending notice, relevant medical documentation, and a short explanation of the unresolved discrepancy. Ask for the missing item to be specified in writing and for the record to be reviewed without another unnecessary submission.

    A state insurance department may help with a regulated insurance complaint; identify the correct regulator through the NAIC state department directory. For a self-funded employer plan, the Department of Labor may be more relevant. Keep private patient information out of public reviews and open email channels.

    Questions to ask before alleging a pattern

    Was the same document requested for the same claim, or for separate claims? Was it sent to the right portal or fax line? Did the payer acknowledge receipt? Were document dates, patient identifiers, and provider identifiers correct? Are multiple cases affected, or is this one unresolved file? A defensible investigation answers these questions before asserting a systematic practice.

    For an example of a broader record-request investigation checklist, compare the documentary evidence rather than relying on the number of phone calls alone. The objective is a traceable resolution and a fair account of what happened.

    Frequently asked questions

    Should I rely on a phone call alone? No. Preserve the written determination, reference numbers, and submission receipts.

    Does a complaint replace an appeal? Usually not. Follow the formal procedure and deadlines for the particular plan.