Prior Authorization Statistics for 2026: What the Numbers Show

Prior authorization remains one of the largest administrative burdens in U.S. healthcare. New data published in 2026 shows that denial rates differ sharply by insurance market, insurer and type of care.

Among 14 large insurers reporting 2025 data, 12% of standard prior authorization requests were denied in Medicare Advantage, 14% in Medicaid managed care and 18% in ACA Marketplace plans. When denied standard requests were appealed, insurers overturned 67% of Medicare Advantage denials, 47% of Medicaid denials and 43% of Marketplace denials.

The newest data also reveals severe pressure points. In a federal review of post-acute care, Medicare Advantage insurers denied 65% of requests for long-term acute care hospitals and 54% of requests for inpatient rehabilitation facilities. Skilled nursing facility requests had a lower 12% denial rate, but insurers overturned 95% of the SNF denials that patients or providers appealed.

The administrative burden remains high for medical practices. The American Medical Association's latest national physician survey found that physicians and their staff complete an average of 40 prior authorizations per physician each week and spend 13 hours on the work. CMS estimates an annual burden of about 700 hours and $34,000 per provider.

Data note: This article uses the newest national information available as of September 16, 2026. The 2025 insurer-reported rates, 2024 Medicare Advantage administrative totals, December 2025 physician survey and June 2024 post-acute care review measure different populations. They should not be combined into a single national denial rate.

Key Prior Authorization Statistics for 2026

What Do the New 2025 Insurer Reports Show?

CMS required impacted payers to publish selected prior authorization metrics by March 31, 2026. A KFF analysis of the new reports examined data from 14 unique insurers.

Those insurers represented:

• 25 million Medicare Advantage enrollees, or 69% of total enrollment
• More than 35 million Medicaid managed care enrollees, or 54% of enrollment
• Nearly 11 million ACA Marketplace enrollees in 28 states, or 74% of enrollment through the federally facilitated Marketplace

In 2025, the insurers denied 12% of standard Medicare Advantage requests, 14% of standard Medicaid managed care requests and 18% of standard ACA Marketplace requests. Denial rates for expedited requests were slightly lower at 10%, 12% and 16%, respectively.

The averages hide wide variation between companies. Standard-request denial rates ranged from 5% to 17% in Medicare Advantage, 2% to 23% in Medicaid managed care, and 3% to 25% in the ACA Marketplace.

Rates also varied within the same company. UnitedHealth Group, for example, denied 17% of standard requests in Medicare Advantage, 11% in Medicaid managed care and 21% in the ACA Marketplace. This means a provider cannot assume that one insurer uses the same authorization approach across all of its products.

The dataset has limits. It excludes prescription drugs and combines many types of medical services into broad totals. Some optional metrics were reported inconsistently, and KFF found that the reports could be difficult to locate on insurer websites. Still, the reports provide the first broad cross-market view under the new CMS transparency requirements.

Why Do 2026 Reports Show Both a 7.7% and 12% Medicare Advantage Denial Rate?

Both figures are valid, but they answer different questions.

The 7.7% rate comes from full-year 2024 Medicare Advantage data submitted to CMS. It covers 52.8 million determinations across the market and includes requests denied fully or partially.

The 12% rate comes from public 2025 reports by 14 large insurers and applies specifically to standard requests. The reporting definitions and included organizations differ from the older dataset.

It would therefore be misleading to say the Medicare Advantage denial rate increased from 7.7% to 12%. A true year-over-year comparison requires the same insurers, definitions and request categories in both years.

How Many Medicare Advantage Prior Authorizations Are Processed?

Medicare Advantage insurers made 52.8 million prior authorization determinations in 2024, according to KFF's analysis of CMS administrative data. That was up from 49.8 million in 2023.

Insurers denied 4.1 million of the 2024 requests fully or partially, producing the 7.7% market-wide rate. The rate was 6.4% in 2023 and 7.4% in 2022.

The growth in total determinations partly reflects Medicare Advantage enrollment. Enrollment rose from about 22 million people in 2019 to 33 million in 2024. Requests per enrollee remained relatively stable at 1.7 in 2024, compared with 1.8 in 2023.

Traditional Medicare uses prior authorization for a narrower group of services. Just over 625,000 requests were submitted for traditional Medicare beneficiaries in fiscal year 2024, or approximately two requests for every 100 beneficiaries. The programs should not be compared without accounting for the different services subject to review.

How Often Are Prior Authorization Denials Overturned?

The latest insurer reports found that appeals frequently produced a favorable result. Among appealed standard-request denials from 2025, insurers overturned:

• 67% in Medicare Advantage
• 47% in Medicaid managed care
• 43% in ACA Marketplace plans

The insurer-level results were even more varied. Medicare Advantage overturn rates ranged from 40% to 93%. Medicaid managed care rates ranged from 22% to 81%, and Marketplace rates ranged from 16% to 54%.

The full-market Medicare Advantage data tells a similar story. Only 11.5% of Medicare Advantage denials were appealed in 2024, but insurers overturned 80.7% of those appeals fully or partially. In every year from 2019 through 2024, more than eight in ten appealed denials were overturned.

An overturned decision does not prove that every initial denial was improper. A provider may submit missing documentation during an appeal. However, the combination of a low appeal rate and a high overturn rate suggests that patients may lose access when a practice lacks the time or resources to challenge a denial.

The 2025 AMA Prior Authorization Physician Survey helps explain the low appeal rate:

• 59% of physicians said past experience made them doubt an appeal would succeed.
• 52% cited insufficient staff time or resources.
• 49% said patient care could not wait for the health plan's approval.
• Only 21% said they always appeal an adverse PA decision.

Which Services Face the Highest Denial Rates?

New reports from the HHS Office of Inspector General show that post-acute care can face much higher denial rates than broad market averages.

For requests reviewed during June 2024, 19 Medicare Advantage organizations collectively denied:

• 65% of long-term acute care hospital, or LTCH, admission requests
• 54% of inpatient rehabilitation facility, or IRF, admission requests
• 12% of skilled nursing facility, or SNF, admission requests

An initial denial delayed admission by an average of five to six days across the three settings, according to KFF's analysis of the OIG findings.

Appeals were filed for 36% of LTCH denials, 31% of IRF denials and 18% of SNF denials. Insurers overturned 36% of appealed LTCH denials, 43% of IRF denials and 95% of appealed SNF denials.

The SNF results deserve particular attention. The OIG's SNF report found that denial rates varied from 0.4% to 23% among the organizations reviewed. Requests for nursing home residents who needed SNF-level care were denied 40% of the time, compared with 11% for other enrollees.

The OIG also found differences based on who processed the request. NaviHealth handled half of the reviewed SNF requests and denied 14%, compared with 11% for requests handled internally by the Medicare Advantage organization and 9% for other contractors. When a naviHealth denial was appealed, 97% were overturned.

These post-acute figures come from a defined one-month review, not all Medicare Advantage services. They should be used to identify high-risk service categories, not as a national denial rate for every authorization.

How Long Do Insurers Take to Decide?

The new 2025 public reports suggest that the typical decision was much faster than the maximum federal deadline. Across the 14 insurers analyzed by KFF, the median response time for a standard request was approximately one day in Medicare Advantage, Medicaid managed care and the ACA Marketplace.

For expedited requests, median response time was about 0.4 days in Medicare Advantage, 0.8 days in Medicaid managed care and one day in Marketplace plans.

The median does not describe every case. It also does not measure how long a provider spends gathering documentation before submission, answering requests for more information or appealing a denial. The OIG post-acute review shows that a denial and appeal can still add several days to a patient's wait even when the first decision is issued quickly.

How Much Staff Time and Money Does Prior Authorization Consume?

The AMA surveyed 1,000 practicing U.S. physicians in December 2025, including 400 primary care physicians and 600 specialists. It found that practices complete an average of 40 prior authorizations per physician each week.

Physicians and their staff spend an average of 13 hours each week on this work. Forty percent of physicians said they employ staff who work exclusively on prior authorization.

CMS estimates that requesting prior authorization costs providers between $20 and $50 per hour. CMS translates the burden into approximately 700 hours and $34,000 per provider each year.

The first request is only part of the cost. Practices may also have to correct submissions, locate records, call payers, complete peer-to-peer reviews, monitor expiration dates, appeal denials and reschedule care.

How Does Prior Authorization Affect Patients?

The AMA survey found that 95% of physicians believe prior authorization delays access to necessary care at least sometimes. Seventy-nine percent said the process can cause patients to abandon a recommended course of treatment.

Physicians also reported that:

• 92% believe PA has a somewhat or significantly negative effect on patient outcomes.
• 26% said PA had led to a serious adverse event for a patient in their care.
• 20% reported a patient hospitalization associated with PA.
• 22% reported a life-threatening event or an intervention needed to prevent permanent harm.
• 8% reported disability, permanent bodily damage, a congenital anomaly, a birth defect or death.
• 88% said PA interferes with continuity of care.
• 61% said it at least sometimes destabilizes a patient who had been stable on an existing treatment.

These are physician-reported experiences. They do not prove that prior authorization was the only cause in every case. They do show how frequently physicians associate the process with delays and clinical harm.

Public concern is also widespread. A 2025 KFF Health Tracking Poll found that 73% of U.S. adults considered insurer delays and denials a major problem. Among insured adults, 24% said an insurer had delayed a requested service, treatment or medication in the previous two years.

Can Prior Authorization Increase Healthcare Use?

Prior authorization is intended to reduce unnecessary spending. Physicians often report that it shifts or increases care instead.

In the AMA survey, 88% said PA leads to higher overall use of healthcare resources at least sometimes. Among the effects reported:

• 75% cited ineffective initial treatment, including step therapy.
• 73% cited additional office visits.
• 47% cited immediate care or emergency room visits.
• 32% cited hospitalizations.

This does not mean every authorization increases total cost. It shows that a delayed service or required treatment sequence can create work elsewhere in the healthcare system.

How Often Are Denials Inappropriate?

A landmark 2022 HHS OIG review examined samples of prior authorization and payment denials issued by 15 large Medicare Advantage organizations in June 2019.

The OIG found that 13% of the denied PA requests met Medicare coverage rules and likely would have been approved under original Medicare. It also found that 18% of denied payment requests met both Medicare coverage and Medicare Advantage billing rules.

Reviewers found that insurers sometimes applied clinical criteria not contained in Medicare coverage rules or said documentation was missing when sufficient information was already in the medical record. Some payment denials involved human or processing-system errors.

The results cannot be treated as a 2026 national error rate because the OIG reviewed a defined sample from 2019. The study remains relevant because the new 2026 post-acute findings again show large insurer differences and high overturn rates for some services.

What Prior Authorization Rules Changed in 2026?

The CMS Interoperability and Prior Authorization Final Rule introduced several operational requirements beginning January 1, 2026.

Impacted payers generally must:

• Send decisions within 72 hours for expedited requests
• Send decisions within seven calendar days for standard requests
• Provide a specific reason when a request is denied
• Publicly report selected prior authorization metrics each year

The seven-day and 72-hour decision requirements do not apply to Qualified Health Plan issuers on federally facilitated exchanges. The rule also excludes prior authorization decisions for drugs.

The first public metrics were due by March 31, 2026. These are the reports used in KFF's new cross-market analysis. The disclosures improve transparency, but differences in covered services, patient populations and reporting practices still limit direct comparisons.

The next major deadline is January 1, 2027. Impacted payers generally must implement FHIR-based prior authorization APIs. These systems are designed to identify documentation requirements, support electronic requests and return approvals, requests for more information or denials with a specific reason.

CMS estimates that its interoperability and prior authorization policies could save approximately $15 billion over ten years. That is a projected policy impact, not money already saved.

Are Voluntary Insurer Reforms Reducing the Burden?

More than 60 health insurers announced voluntary reform commitments in June 2025. They promised to reduce the number of services subject to PA, improve continuity when patients change plans, increase transparency, standardize electronic PA and expand real-time responses.

In May 2026, CMS reported that leading health plans said they had eliminated 11% of prior authorization requirements across medical services, resulting in 6.5 million fewer authorizations. One large national plan reported plans to eliminate requirements for 30% of services.

These are health-plan-reported changes. They are evidence of activity, but they do not by themselves establish how much provider time or patient delay has been eliminated.

The AMA survey, conducted in December 2025, provides an early baseline:

• Only 33% of physicians believed the voluntary commitments were likely to make a meaningful difference.
• Only 24% agreed that medical-necessity denials were reviewed by an appropriately licensed and qualified clinician.
• Only 16% of physicians participating in peer-to-peer reviews said the insurer's reviewer often or always had appropriate qualifications.
• Only 5% reported contracts with plans offering exemptions such as gold-card programs.

Later data will be needed to measure whether the 2026 reductions produce sustained improvements for patients and practices.

What Can Medical Practices Do With These Findings?

These findings show where prior authorization problems most often begin and where practices can tighten their workflow to reduce delays, avoid preventable denials, and improve follow-up.

Verify requirements before scheduling treatment

Confirm the patient's plan, whether the service requires authorization, the submission route and the current clinical criteria. Requirements can differ between products sold by the same insurer.

Build payer-specific documentation checklists

Identify the diagnoses, conservative treatment history, test results, imaging, clinical notes and site-of-service information required for each payer and procedure.

Track each request as a time-sensitive case

Record the submission date, reference number, request type, expected decision date, status, expiration date and approved units or visits. Escalate expedited requests that pass 72 hours and standard requests that pass the applicable deadline.

Appeal denials based on the stated reason

High overturn rates do not guarantee success, but they show why the first denial should not automatically be treated as final. Use the denial reason to decide whether to add documentation, correct an administrative error, request peer review or file a formal appeal.

Measure performance by payer and service

Useful measures include:

• First-submission approval rate
• Requests for additional information
• Median and longest decision time
• Denial rate by payer, product and procedure
• Appeal rate and overturn rate
• Authorizations that expire before treatment
• Claims denied despite an authorization
• Hours spent per request and appeal

Broad averages can hide the service lines and payer products creating the greatest risk.

Prepare for electronic prior authorization

Ask EHR, practice-management and clearinghouse vendors how they will support the 2027 FHIR API requirements. Technology may reduce manual status checks, but it will not correct incomplete documentation or replace ownership of unresolved cases.

Conclusion

The newest 2026 evidence provides a clearer view of prior authorization across insurance markets. In 2025 insurer reports, standard-request denial rates averaged 12% in Medicare Advantage, 14% in Medicaid managed care and 18% in ACA Marketplace plans. Appeals reversed many of those denials, including 67% of appealed standard Medicare Advantage denials.

The burden is not distributed evenly. Denial rates vary widely by insurer and market, while some post-acute services face rates above 50%. For skilled nursing facility care, 95% of appealed denials in the OIG review were overturned.

Practices also continue to report substantial administrative and clinical effects. Prior authorization consumes an average of 13 hours per physician each week, and CMS estimates an annual cost of approximately $34,000 per provider. Physicians frequently report delayed or abandoned care.

The 2026 transparency and decision-time requirements are meaningful steps. The 2027 API deadline may reduce more manual work. Until measurable results appear, practices still need clear ownership, payer-specific documentation, active status tracking and a consistent appeal process. When internal teams cannot maintain that level of follow-up, a structured prior authorization workflow can help prevent avoidable delays and protect reimbursement.