HHS OIG reports highlight MA insurer denials for long-term care, rehab services and SNF admissions

The Department of Health and Human Services Office of Inspector General June 11 released two reports on high rates of coverage denials by Medicare Advantage organizations regarding long-term care, inpatient rehabilitation services and admissions to skilled nursing facilities. One report highlights significantly higher rates of coverage denials by UnitedHealth, Humana and CVS Health compared to other MAOs in 2024. Collectively, MAOs overturned 36% of long-term care hospital coverage denials and 43% of inpatient rehabilitation facility denials following appeals. Some IRF overturn rates ranged from 14% to 86%, the report found. In some instances, high denial rates initially granted by contractors on behalf of MAOs were later overturned on appeal by the MAO.

The second report released today found that MAOs overturned 95% of appealed prior authorization denials for SNF admissions, raising concerns about initial denials. The report found that NaviHealth, a UnitedHealth subsidiary, processed half of all requests for SNF admissions and denied 14%, a higher rate than MAOs that processed requests internally (11%) and other contractors (9%). MAOs overturned 97% of the denials issued by NaviHealth following appeals. The AHA in 2024 urged HHS OIG to further scrutinize MAOs' use of prior authorization for post-acute care.