WASHINGTON, D.C. — The Department of Health and Human Services Office of Inspector General released two reports on Thursday detailing prior authorization practices within Medicare Advantage plans. One report found prior authorization denial rates for long-term acute care and inpatient rehabilitation services ranged from 8% to 80% among different insurance companies.
A second HHS Inspector General report focused on prior authorization requests for skilled nursing facility care and found that Medicare Advantage plans reversed 95% of denials when patients appealed. Rosemary Bartholomew, lead author of the reports, said, "We're looking at an extremely high overturn rate." Bartholomew added, "That really raises concerns that there's a breakdown happening at that first request step." According to the HHS OIG report, insurers overturned NaviHealth's denials of nursing home care 97% of the time when patients appealed.
The first OIG report analyzed requests submitted in June 2024 across 19 Medicare Advantage groups. UnitedHealthcare, CVS Health, and Humana recorded the highest prior authorization denial rates for long-term acute care and inpatient rehabilitation services, with rejections exceeding 70% in some instances. Nearly 20 million people in the U.S. are enrolled in Medicare Advantage plans managed by these three companies. Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh, stated, "These denial rates are quite staggering." Yaver said, "It's another data point that reinforces what a lot of Americans have already been articulating a lot of frustration about — which is that healthcare decisions are being made with profit rather than medical necessity in mind."
NaviHealth, a subsidiary of UnitedHealth Group, evaluated requests for rehabilitative care for Medicare Advantage plans under investigation. NaviHealth uses artificial intelligence to assess patient care needs for prior authorization requests. The services analyzed in the reports are typically used by patients recovering from strokes, heart conditions, and severe fractures. Yaver said, "This is an area that is unfortunately high cost, high stakes." She added, "Healthcare decision-making is extremely consequential."
The OIG recommended that the Centers for Medicare & Medicaid Services (CMS) establish regular collection of prior authorization data. The office also recommended that CMS investigate the varying prior authorization denial rates among different insurers. Insurers state that prior authorization programs are designed to control healthcare costs by limiting unnecessary medical procedures and treatments. A spokesperson for Aetna, the insurance arm of CVS Health, said, "We review requests promptly, offer a clear appeals process, and are leading the way for continuous patient-centered improvements."