Series: Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

Announced on 06/17/2024 | Last Modified on 06/08/2026 | Series Number: SRS-E-26-004

Status

Active

Agency

Centers for Medicare and Medicaid Services

OBJECTIVE

Medicare Advantage plans must cover at least the same services as original Medicare, but Medicare Advantage Organizations (MAOs) may impose additional administrative requirements, such as requiring prior authorization before certain services can be provided. Prior OIG work found that MAOs sometimes denied prior authorization requests for post-acute care after a qualifying hospital stay even though the requests met Medicare coverage rules. We will review the extent to which selected MAOs denied requests for post-acute care in long-term acute care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities, and the extent to which denied requests were appealed and overturned. We will also conduct medical record reviews for a sample of cases to determine the extent to which MAOs denied requests for post-acute care admissions that met Medicare coverage rules.

There are three projects in this series.

There are 3 projects in this series.

ACTIVE PROJECTS IN THIS SERIES (1)

Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

Project OEI-09-24-00332 • Announced on May 15, 2026

COMPLETED PROJECTS IN THIS SERIES (2)

Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

Project OEI-09-24-00330 • Completed on June 8, 2026

Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

Project OEI-09-24-00331 • Completed on June 8, 2026

TIMELINE

June 17, 2024

Series Number SRS-E-26-004 Assigned
June 17, 2024

Projects Announced
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care - OEI-09-24-00330
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care - OEI-09-24-00331
May 15, 2026

Project Announced
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care - OEI-09-24-00332
June 8, 2026

Project Complete - OEI-09-24-00330
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care complete. This evaluation resulted in 2 recommendations.
June 8, 2026

Project Complete - OEI-09-24-00331
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care complete. This evaluation resulted in 3 recommendations.
Today

1 Evaluation In-Progress
Est FY2028

Estimated Fiscal Year for Series Completion

2 REPORT PUBLISHED

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)

Among the 19 MAOs in this review, the 3 largest MAOs by enrollment denied prior authorization requests for care in LTCHs and IRFs at higher rates than most of their peers in June 2024.
When enrollees appealed, MAOs collectively overturned 36 percent of LTCH denials and 43 percent of IRF denials, indicating that some enrollees were initially denied medically necessary care. Some MAOs had much higher overturn rates than their peers. For example, IRF overturn rates ranged by MAO from 14 percent to 86 percent.
In some cases, high denial rates were driven by contractors that denied prior authorization requests on behalf of the MAOs, many of which were later overturned on appeal by the MAO. This raises concerns about whether contractors are receiving appropriate training and oversight from MAOs.

26-E-09-023.01 to CMS - Open Unimplemented

Update expected on 12/07/2026

CMS should regularly collect request-level prior authorization data that include standardized service type and contractor information.

26-E-09-023.02 to CMS - Open Unimplemented

Update expected on 12/07/2026

CMS should assess reasons for the wide variation in LTCH and IRF denial and overturn rates across MAOs and contractors and take action as appropriate.

View in Recommendation Tracker

Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials (OEI-09-24-00331)

In June 2024, the 19 MAOs in this review collectively denied 12 percent of requests for SNF admission. MAO denial rates ranged from 23 percent to 0.4 percent.
Enrollees and their providers appealed 18 percent of SNF denials. When SNF denials were appealed, MAOs overturned 95 percent in favor of the enrollee. The extremely high overturn rate indicates that some enrollees were initially denied medically necessary care and raises concerns about denials that were not appealed.
The contractor naviHealth processed half of all requests for SNF admission and denied 14 percent of them—a higher denial rate than MAOs that processed requests internally (11 percent) and other contractors (9 percent). MAOs later overturned 97 percent of SNF denials issued by naviHealth when enrollees appealed. This raises concerns about whether contractors are receiving appropriate training and oversight from MAOs. NaviHealth is a subsidiary of the MAO United Health Group, Inc.
MAOs and their contractors denied requests for SNF-level care from nursing home residents 40 percent of the time, a much higher rate than requests from all other enrollees (11 percent).

26-E-09-024.01 to CMS - Open Unimplemented

Update expected on 12/07/2026

CMS should take action to address any breakdowns in the initial reviews of SNF admission requests that are driving the extremely high overturn rate of SNF admission denials.

26-E-09-024.02 to CMS - Open Unimplemented

Update expected on 12/07/2026

CMS should assess the reasons for variation in SNF denial rates across MAOs and contractors and take action as appropriate.

26-E-09-024.03 to CMS - Open Unimplemented

Update expected on 12/07/2026

CMS should assess reasons for the differences in SNF denial rates between nursing home residents and other enrollees and take action as warranted.

View in Recommendation Tracker

Work Plan Type

Office of Evaluation and Inspections

HHS Agencies

Centers for Medicare and Medicaid Services

Issue Areas

Nursing Homes, Nursing Facilities, and Assisted Living Facilities Managed Care

Target Groups

Financial Groups

Medicare C

Series: Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

OBJECTIVE

ACTIVE PROJECTS IN THIS SERIES (1)

Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

COMPLETED PROJECTS IN THIS SERIES (2)

Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care

TIMELINE

2 REPORT PUBLISHED

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)

Recommendation Details (2)

Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials (OEI-09-24-00331)

Recommendation Details (3)