Two June 8 reports from the HHS Office of Inspector General highlighted post-acute care denials and overturned appeals from Medicare Advantage organizations.
Both reports focused on June 2024, looking across 19 MA organizations.
The first report found the three largest MA organizations — UnitedHealth Group, Humana and CVS Health, Aetna’s parent company — denied prior authorization requests for long-term acute care hospitals and inpatient rehabilitation facilities at rates exceeding their peers.
CVS had the steepest denial rate for admission requests to long-term care hospitals at 80%, followed by Humana at 72% and UnitedHealth at 71%. The rate for the 16 other evaluated MA organizations was 42%.
UnitedHealth had the greatest denial rate for admission requests to inpatient rehabilitation facilities at 66%. Humana trailed at 54%, followed by CVS at 51%. The overall rate for the remaining organizations was 41%.
For-profit contracts had higher denials rates than nonprofit ones, the report also found.
Looking collectively at the MA organizations, the overturn rate for appealed denials was 36% for long-term acute care hospitals and 43% for inpatient rehabilitation facilities requests. Overturn rates upon appeal for long-term acute care hospitals requests were more than 50% for both Elevance and UnitedHealth. Overturn rates with appeals for inpatient rehabilitation facilities requests surpassed 80% for BCBS Michigan, Elevance and CVS.
Contractor naviHealth, owned by UnitedHealth’s Optum, processed more than one-third of these requests across the 19 organizations. NaviHealth had denial rates of 73% and 68% for long-term acute care hospitals and inpatient rehabilitation facilities, respectively, higher than both MA organizations’ internal processing and use of other contractors.
The second report showed how the MA organizations collectively denied 12% of requests for skilled nursing facility admission, with individual organizations’ rates ranging from 0.4% to 23%. As with the first report, naviHealth played a major role, contributing to a higher denial rate than requests processed internally or through another contractor. The report also identified how MA organizations and their contractors denied nursing home residents’ requests for SNF-level care 40% of the time, versus 11% for all other enrollees.
Of the 18% of denials that were appealed, MA organizations overturned 95% in the enrollee’s favor. UnitedHealth, in particular, overturned its appealed denials 99.7% of the time.
While OIG recommended gathering request-level prior authorization data and evaluating the variations in denial and overturn rates, CMS did not explicitly agree.
“Our priority is helping patients get the care they need without unnecessary delays,” a CVS spokesperson told Becker’s. “When combined with timely clinical information from our provider partners, prior authorization supports safe, effective and affordable care. We review requests promptly, offer a clear appeals process and are leading the way for continuous patient-centered improvements.”
In a June 11 statement, AHIP said OIG disregarded research on spending and quality issues in post-acute care, along with the context of denials, including missing documentation and other administrative reasons. AHIP also emphasized insurers’ voluntary commitments to streamline prior authorization.
“The reports ignore serious, well-documented concerns about wide variations in the cost and quality of post-acute care and skilled nursing facilities. More than 35 million Americans actively choose MA because it provides them with better, more affordable care — including helping seniors transition to high-quality, clinically appropriate care settings to support their rehab and recovery,” an AHIP spokesperson said.
Becker’s contacted Humana and UnitedHealth, as well as Optum and organizations with SNF denial rates above 9%, and will update this story if more information becomes available.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.