Medicare Advantage Denial Rates Raise Questions About Care Access

A recent report by the U.S. Department of Health and Human Services Office of Inspector General (OIG) has spotlighted significant denial rates among top Medicare Advantage insurers regarding post-hospitalization care requests. Major insurers including UnitedHealth Group, Humana, and CVS Health under the Aetna brand have been recognized for frequently rejecting patient transfers to long-term care hospitals and rehabilitation facilities. These facilities play a crucial role in providing extended medical supervision or intensive therapy for patients recovering from severe health incidents.

The OIG's analysis reviewed prior authorization decisions from the 19 largest Medicare Advantage plans as of June 2024, uncovering a 65% denial rate for long-term care hospital admissions and a 54% denial rate for rehabilitation facility entries. Among insurers, UnitedHealth Group, Humana, and CVS Health exhibited particularly high denial rates, rejecting over 70% of long-term care hospital transfers. Specifically, CVS Health showed an 80% denial rate, while Humana and UnitedHealth stood at 72% and 71%, respectively. Rehabilitation requests were denied at rates of 66% by UnitedHealth, 54% by Humana, and 51% by CVS Health.

Appeal outcomes showed insurers reversing 36% of long-term hospital and 43% of rehabilitation denials, suggesting that initial assessments might have improperly denied necessary care. The for-profit insurers reported higher denial rates than nonprofit entities, sparking discussions on how financial models impact healthcare decisions. Though the report does not classify these denials as improper, it raises concerns about potential discrepancies in service access and variability in covered services. Extended hospitalizations due to appeals increase patient risks, such as infection or injury, during prolonged inpatient stays.

The OIG report recommends that the Centers for Medicare & Medicaid Services (CMS) collect more precise data to probe into denial rate discrepancies. However, CMS has taken a neutral position on the report's findings. Professionals requiring further guidance on navigating Medicare Advantage coverage appeals are encouraged to refer to the Centers for Medicare & Medicaid Services resources for detailed information.