Challenge:

A state insurance department sought to assess differences in utilization management approaches—including claim denials and prior authorization requirements—between traditional Medicare, Medicare Advantage plans, and Medicaid for their residents. Understanding these variations was critical for evaluating their impact on patient access and guiding regulatory discussions.

Solution:

Our team conducted a comprehensive data analysis using the State’s All-Payer Claims Database (APCD), supplemented by a targeted literature review. The study examined:

• Differences in claim denial rates and prior authorization requirements across insurance types.

• The impact of utilization management practices on healthcare resource use and costs.

• Insurer-specific trends affecting patient access to services.

Results:

The findings were compiled into a detailed report shared with the state legislature, providing data-driven insights into the use of utilization management practices by Medicare Advantage plans. These insights played a key role in informing regulatory discussions, helping policymakers assess how such practices impact healthcare access and whether further oversight was needed.