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Largest MA Organizations Have Disproportionate Denial Rates for Some Post-Acute Care
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG)—a watchdog agency—has released a second report on Medicare Advantage (MA) organizations denying coverage for care after an injury or illness. The first report discussed high levels of denials for people seeking admission to a skilled nursing facility. Now, the agency has shown how the three largest MA organizations have disproportionately high denial rates for some other forms of post-acute care, raising questions about how these coverage determinations are made.
Prior Authorization and Plan Payments
Prior authorization requires enrollees to get permission in advance to have a service, procedure, or item covered by insurance. Plans are paid a set amount in advance to provide care for each enrollee. This number does not go up if the plan has to pay more than expected; the number also doesn’t go down if the plan pays less than expected. This means that plans can profit if they spend less than they were paid to cover the enrollee.
Plans can profit if they spend less than they were paid to cover an enrollee.
Previous OIG work has found concerning patterns of prior authorization denials and the agency has flagged the payment incentive in the past, noting that prior authorization must be closely monitored because plans may be using it to increase profits through denials of necessary care.
Post-Acute Care
Post-acute care is necessary for some people after hospitalization or other treatment for an injury or illness. It can take many forms, including admission to a skilled nursing facility, Medicare home health, or transfer to a Long-Term Care Hospital (LTCH) or Inpatient Rehabilitation Facility (IRF).
LTCH care is for people with significant, complex conditions that require a hospital level of care. IRFs are for people who need intensive rehabilitation services like occupational, physical, or speech therapy.
New OIG Findings
OIG reviewed data from the 19 largest MA organizations by enrollment. The agency found that those organizations denied coverage for 65% of LTCH and 54% of IRF prior authorization requests on average.
But all MA organizations were not the same. The three largest—UnitedHealth, Humana, and CVS (the parent company of Aetna)—cover over 20 million people and denied coverage for LTCH and IRF care more often than most other MA payers. For LTCH, CVS denied 80% of coverage, Humana 72%, and UnitedHealth 71%. For IRF, UnitedHealth led in denials with 66%, Humana at 54%, and CVS at 51%.
By comparison, the qualifying organization with the lowest rate of denials for LTCH, UPMC Health System, denied 8% of requests. For IRF, Healthfirst denied 4% of requests.
Denial rates were higher for for-profit plans than not-for-profit plans.
OIG found that the denial rates were higher for for-profit plans than not-for-profit plans and that an organization’s use of outside contractors could signal both higher rates of denials and higher rates of overturns on appeal. This mirrors the findings in the first report, where the contractor naviHealth had nearly all of its denials overturned on appeal.
Appeals Come at a Cost to Enrollees
OIG’s review found that these decisions were overturned at a high rate: 36% of LTCH denials and 43% of IRF denials were overturned on appeal. Importantly, even when an enrollee wins an appeal, it can come at significant cost. The agency found that the median time from the initial request to the appeal decision was six days for LTCH requests and five days for IRF requests, but “8 percent of IRF appeals and 16 percent of LTCH appeals took 10 days or more to receive a decision.”
These delays mean that enrollees are going without needed care, paying out of pocket, or are trapped in higher-cost settings.
Prior Authorization Needs Major Reforms
OIG notes that these wide variations between plans signal that some plans may be inappropriately denying care to enrollees. At Medicare Rights, we will continue to urge CMS and other policymakers to focus on the harms prior authorization can do to enrollee health and well-being. MA organizations must not be allowed to deny or delay necessary care and violate Medicare’s promise of guaranteed, high quality, and affordable coverage.
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One Comment on “Largest MA Organizations Have Disproportionate Denial Rates for Some Post-Acute Care”
Stephen Acciani
June 25, 2026 at 5:22 pmThere is no doubt PAs need reform but once again an article here only gives part of the story. For instance this fails to mention that many providers submit incomplete data or incorrect codes. These are automatic denials. In addition, Medicare itself denies very little and for that reason if you can afford original Medicare and a supplement do it. But let’s compare: Plan N and a good Rx plan will cost $450-500. An MA plan will cost less than $100, some plans cost nothing, $0. So the Medicare Rights Center, although they do lots of good work, are just another group who hate anything that isn’t 100% government run and the articles here always heavily lean that way.