Prior authorization and utilization management for post-acute home health in Medicare Advantage: the motivations, players, processes, unique challenges, and impacts on patient care.

ABSTRACT: In 2024, 90% of Medicare Advantage (MA) enrollees were in a plan that required prior authorization of home health care. We conducted semi-structured interviews with 44 leaders of MA plans, post-acute care (PAC) management companies, and home health agencies (HHAs) across the country to understand their experiences with prior authorization and utilization management (UM) of post-acute home health care. Our analysis of these interviews revealed that representatives of MA plans and PAC management companies report varying motives and approaches to prior authorization for post-acute home health care, resulting in varied experiences for HHAs. Both MA plan and HHA representatives view prior authorization and UM of post-acute home health as burdensome, and each have taken distinct approaches to ma

SUBMITTER: Thomas KS 

PROVIDER: S-EPMC11886789 | biostudies-literature | 2025 Mar

REPOSITORIES: biostudies-literature