The HHS Office of Inspector General released two reports on post-acute denials in Medicare Advantage. The findings are worth reading in full.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials
The first looked at skilled nursing facility admissions. Plans denied 12 percent of requests and overturned 95 percent of the denials enrollees appealed.
The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates
The second examined long-term acute care and inpatient rehabilitation. The three largest plans denied these requests at some of the highest rates, with overturn rates as high as 86 percent.
Both reports point at the same risk: high overturn rates expose weak first-level review, and contractors drive much of the gap.
Continue the Conversation at RISE West 2026
Medicare Advantage Prior Authorization – OIG Findings
Session on Thursday, September 3 at 2:05pm
Rosemary Bartholomew and Ivy Ngo of HHS OIG will present findings from their latest body of work examining prior authorization practices in Medicare Advantage. This session will provide an inside look at how plans are applying prior authorization, where inappropriate denials or delays persist, and how oversight is evolving.