Office of Evaluation and Inspections Data Briefs
Article Publication Date
Summary
The Department of Health and Human Services' (HHS) Office of the Inspector General (OIG) recently issued two data briefs on Medicare Advantage Organizations' (MAOs) use of prior authorization in post-acute care following a hospital stay.
The first brief is titled "The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates", OEI-09-24-00330, June 2026. Of the 19 MAOs included in the OIG review, the three largest MAOs by enrollment denied prior authorization requests for care in Long-Term Care Hospitals (LTCHs) and Inpatient Rehabilitation Facilities (IRFs) at higher rates than most of their peers in June 2024. When enrollees appealed, MAOs collectively overturned 36% of LTCH denials and 43% of IRF denials, indicating that some enrollees were initially denied medically necessary care. IRF overturn rates ranged from 14% to 86% across MAOs. OIG recommends (1) CMS regularly collect prior authorization data, including service type and contractor information, and (2) assess the reasons for the wide variation in LTCH and IRF denial and overturn rates across MAOs and contractors, and take appropriate action.
The second brief is titled "Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials", OEI-09-24-00331, June 2026. In this data brief, OIG reported that the 19 MAOs included in its review collectively denied 12% of requests for Skilled Nursing Facility (SNF) admission in June 2024. MAO denial rates ranged from 0.4% to 23%. Additionally, enrollees and their providers appealed 18% of SNF denials. When SNF denials were appealed, MAOs overturned 95% in favor of the enrollee. According to the report, the extremely high overturn rate indicates that some enrollees were initially denied medically necessary care and raises concerns about denials that were not appealed. Additionally, MAOs and their contractors denied requests for SNF-level care from nursing home residents 40% of the time, a higher rate than for all other enrollees (11%). OIG recommends (1) CMS address the initial reviews of SNF admission requests, driving the high overturn rate of admission denials, (2) assess reasons for variation in SNF denial rates among MAOs and contracts, and (3) assess reasons for differences in SNF denial rates between nursing home and non-nursing home residents, and take action as needed.
The first brief is titled "The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates", OEI-09-24-00330, June 2026. Of the 19 MAOs included in the OIG review, the three largest MAOs by enrollment denied prior authorization requests for care in Long-Term Care Hospitals (LTCHs) and Inpatient Rehabilitation Facilities (IRFs) at higher rates than most of their peers in June 2024. When enrollees appealed, MAOs collectively overturned 36% of LTCH denials and 43% of IRF denials, indicating that some enrollees were initially denied medically necessary care. IRF overturn rates ranged from 14% to 86% across MAOs. OIG recommends (1) CMS regularly collect prior authorization data, including service type and contractor information, and (2) assess the reasons for the wide variation in LTCH and IRF denial and overturn rates across MAOs and contractors, and take appropriate action.
The second brief is titled "Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials", OEI-09-24-00331, June 2026. In this data brief, OIG reported that the 19 MAOs included in its review collectively denied 12% of requests for Skilled Nursing Facility (SNF) admission in June 2024. MAO denial rates ranged from 0.4% to 23%. Additionally, enrollees and their providers appealed 18% of SNF denials. When SNF denials were appealed, MAOs overturned 95% in favor of the enrollee. According to the report, the extremely high overturn rate indicates that some enrollees were initially denied medically necessary care and raises concerns about denials that were not appealed. Additionally, MAOs and their contractors denied requests for SNF-level care from nursing home residents 40% of the time, a higher rate than for all other enrollees (11%). OIG recommends (1) CMS address the initial reviews of SNF admission requests, driving the high overturn rate of admission denials, (2) assess reasons for variation in SNF denial rates among MAOs and contracts, and (3) assess reasons for differences in SNF denial rates between nursing home and non-nursing home residents, and take action as needed.