Two post-acute care associations are calling on Congress and CMS to overhaul Medicare Advantage plans’ use of prior authorization after two HHS reports found high denial rates for long-term care hospital and skilled nursing facility services.
“These findings confirm what LTCH providers, physicians, patients and families have experienced for years: Medicare Advantage plans are too often standing between medically complex patients and the specialized care their physicians have determined they need,” National Association of Long Term Hospitals President Chris Fox said in a June 15 news release shared with Becker’s. “When access to medically necessary LTCH care is delayed or denied, patients face longer recoveries and increased complications, and potentially worse outcomes.”
The American Health Care Association and National Center for Assisted Living raised similar concerns.
“It’s unconscionable that insurers are making frail seniors and their families jump through numerous hoops at a critical time for their recovery,” AHCA/NCAL President and CEO Clif Porter said in a June 15 news release. “It is time for lawmakers to act and hold these large Medicare Advantage organizations accountable. Our nation’s seniors deserve timely, consistent access to care, pure and simple.”
Both organizations are calling on Congress to make changes.
AHCA/NCAL supports the Medicare Advantage Improvement Act of 2026, which addresses issues surrounding prior authorization, prompt pay, payment clawbacks and transparency.
NALTH is urging more oversight of prior authorization practices for LTCH services, increased transparency around denial rates and appeal outcomes, and holding plans accountable for following Medicare coverage standards.
“NALTH is calling on Congress and CMS to act — not studying, not monitoring, not convening a workgroup — but by taking action,” Mr. Fox said. “NALTH looks forward to working with Congress and CMS to ensure Medicare Advantage beneficiaries receive the care they need, when they need it.”
On June 8, the HHS Office of Inspector General released two reports highlighting 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%, followed by Humana at 54% and CVS at 51%. The overall rate for the remaining organizations was 41%.
The second report showed MA organizations collectively denied 12% of requests for skilled nursing facility admission, with individual organizations’ rates ranging from 0.4% to 23%. The report also found 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.
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.
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