Aetna is giving health care providers, employers, benefits and others a little more information about how one of its major control efforts — prior authorization reviews — works.
Aetna and other health insurers use prior authorization reviews to look at patients' requests for coverage for medical services before the services are provided, in an effort to ward off claims for services that might be unnecessary, outside the scope of a patient's coverage, too expensive, or too dangerous to justify the potential benefits.
The new Aetna prior authorization statistics page shows data for commercial health plans, including employer-sponsored plans and some individual policies, in Colorado, Georgia, Illinois, Indiana, Minnesota, Mississippi, New Jersey, Tennessee, Texas, Wyoming and the District of Columbia.
Each state has its own reporting format. Most charts give full-year data for 2024, but some give data for 2025, and some give data for only part of either 2024 or 2025.
The chart for Texas, for example, shows that Aetna conducted prior authorization reviews for 57,064 requests for coverage and approved 90.9% of the requests.
Patients filed internal appeals for 1,387 of the 5,217 requests that were denied, and internal reviewers overturned 24.7% of those internal appeals.
Patients filed appeals with external reviewers for 338 of the internal appeals that Aetna's own internal reviewers upheld. The external reviewers overturned 33.7% of the external appeals and upheld 211.
The results mean that internal or external reviewers eventually approved 457 of the 5,217 requests for coverage that were denied at the first level of review.
In another state, Indiana, Aetna approved 77% of preauthorization requests, and getting a response took an average of 1.94 business days, according to Aetna.
The backdrop: The new charts could give employers and benefits advisors new insights into what has become a hot political topic.
A majority of insured adults recently told a KFF survey team that prior authorization requirements are a burden.
House committees recently held two hearings where the committee members blasted health insurance company chief executive officers over many concerns, including slow and cumbersome prior authorization processes.
The American Medical Association has been complaining about the processes for years.
Dr. Mehmet Oz, the cardiothoracic surgeon and former medical talk show host who is now the administrator of the Centers for Medicare and Medicaid Services, has made prior authorization simplification a top focus.
But health insurers have defended prior authorization reviews, contending that they can be a good way to detect fraud, waste and abuse and protect patients against procedures that might hurt them.
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