Silna says therapy prior authorizations hide a blind spot

Silna released data showing that partial approvals are affecting 1 in 6 therapy authorization requests across two large Medicare Advantage payers, even as outright denials stay below 1%. The company argues the industry’s focus on denial rates is missing a quieter way patients can still receive less care than doctors prescribe.

Why it matters: - Partial approvals can reduce the number of therapy sessions patients receive even when a request is technically approved. - Silna says that means the industry’s main prior authorization metric, denial rates, can miss a large share of care restrictions. - The issue affects physical therapy, occupational therapy, and speech therapy, three high-volume post-acute care services.

What happened: - Silna analyzed 158,000 authorization requests for physical therapy, occupational therapy, and speech therapy across two of the largest Medicare Advantage payers in the country. - The outright denial rate across those requests was 0.9%. - About 1 in 6 requests came back approved with fewer therapy sessions than the physician originally prescribed. - The analysis found similar partial-approval rates across the three disciplines.

The details: - Physical therapy requests returned with reduced units 15.3% of the time. - Occupational therapy requests returned with reduced units 15.6% of the time. - Speech therapy requests returned with reduced units 16.8% of the time. - A partial approval does not show up in denial-rate reports because the request is still marked approved. - Providers cannot appeal a partial approval as a denial. - Silna says the result is a metric that can look successful while patients receive less care than ordered. - The company said reduced therapy can lead to early discharge or incomplete treatment, including for patients recovering from a stroke. - Silna also said none of those outcomes appear in the numbers reform advocates are tracking.

Between the lines: - The data suggests prior authorization reform may be focused on the wrong bottleneck if it tracks only outright denials. - If partial approvals are common, payers can tighten care without triggering the reporting and appeals pathways tied to denials. - That creates a measurement gap for providers, patients, and policymakers trying to judge access to care. - Jeffrey Morelli, Silna’s co-founder and CEO, said the denial rate is “almost a distraction” when so many requests are approved for fewer sessions. - Kevin Murphy, VP of Revenue Cycle at HealthPRO Heritage, said partial approvals are happening constantly and leave patients with less care than prescribed. - HealthPRO Heritage works across 48 states and serves patients in skilled nursing, senior living, and hospice settings.

What’s next: - HealthPRO Heritage is working with Silna to surface and address partial approvals before they affect patient care. - Silna is positioning its platform as a way to monitor prior authorization, benefit checks, and real-time insurance changes more closely. - More pressure could build for reporting rules that capture partial approvals, not just denials.

The bottom line: - Silna’s message is that prior authorization reform may be undercounting how often patients get less care than doctors order.