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 manage the process but have conflicting views on the utility of these approaches. Home health agency representatives report that prior authorization and UM requirements impact access to care, the way that care is delivered, and ultimately patients' experiences. Our findings warrant additional research and policy attention so that MA plans' UM techniques do not unintentionally cause patient harm, particularly among vulnerable Medicare enrollees in need of post-acute home health care.