WALNUT HILL STUDY EXPOSES SYSTEMIC MEDICARE ADVANTAGE BARRIERS CAUSING DELAYS, DENIALS, AND PATIENT

In 2022, the Office of Inspector General (OIG) found that 13% of denied services in Medicare Advantage met Medicare coverage criteria and should have been approved. The OIG warned that plans may be inappropriately restricting access to necessary care.

Walnut Hill’s 2024 data show the problem is even worse—especially for patients seeking advanced therapies like PNS.

Prior authorization is the process by which a health plan requires providers to obtain approval before delivering certain services or procedures. Intended to control costs and ensure medical necessity, prior authorization can also delay or prevent timely care—especially when approval is denied, appeals drag on, or patients simply give up.

PNS is a minimally invasive, FDA-cleared therapy for chronic pain. Walnut Hill’s study found:

• 29% of patients were denied on their first prior authorization attempt—more than twice the OIG’s 2022 benchmark.
• 28% of patients abandoned care after an initial denial—never appealing or resubmitting.
• Among those who appealed:

          o    56% had their denial overturned.

          o    69% who escalated to a Medicare hearing (OMHA) were approved.

“This isn’t just inefficiency,” Hanna said. “It’s a sorting mechanism that weeds out patients without time, resources, or strong clinical advocates.”

Of the 1,210 patients studied, 210 were denied and never received their PNS therapy. Based on 2024 Medicare Advantage reimbursement rates, Medicare Advantage plans withheld $6.2 million worth of care from patients—highlighting how administrative attrition reduces cost at the patient’s expense.

“Medicare Advantage now covers the majority of eligible seniors,” said Hanna. “With that dominance must come responsibility. Our data show that without reform, prior authorization becomes a silent gatekeeper—not just delaying care but denying it altogether.”

Walnut Hill is urging lawmakers to strengthen transparency and accountability provisions in the bipartisan Improving Seniors’ Timely Access to Care Act of 2025, introduced by Rep. Mike Kelly (R-PA).