The three biggest Medicare Advantage insurers deny requests for inpatient rehab at significantly higher rates than their peers, a new Office of Inspector General report shows.
These findings are concerning, OIG contends, as the share of seniors opting for a Medicare Advantage plan remains high. Those enrollees are also increasingly concentrated in the three biggest plans: CVS Health Corporation, Humana Inc. and UnitedHealth Group, Inc.
High denial rates for inpatient rehabilitation and long-term care could result in millions of people not getting the care they need, OIG added.
Using prior authorization denial and appeal rates for long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs) across 19 of the nation's largest Medicare Advantage organizations, OIG identified serious coverage problems.
In June of 2024, LTCH request denials were at 65%, and IRF denials were at 54% across all 19 Medicare Advantage plans. That shakes out to around 2,100 LTCH denials and 10,500 IRF denials.
But, according to OIG, those denials were driven by a select few payers -- the three biggest included in the study.
CVS Health has the highest LTCH denial rate at 80%, nearly double the rate of the remaining 16 Medicare Advantage organizations combined (42%). Humana's LTCH denial rate was 72%, while UnitedHealth Group had a denial rate of 71%.
It should be noted that Highmark Health had an LTCH denial rate of 73%, although it is not one of the top three biggest Medicare Advantage plans. However, Highmark saw a significantly smaller number of requests -- 63 compared to the hundreds or thousands received by CVS Health, Humana and UnitedHealth Group.
A similar trend persisted in IRF denial rates, though to a lesser extent.
The IRF denial rate for UnitedHealth Group was the highest at 66%, compared to 54% for Humana and 51% for CVS Health.
Again, some smaller payers had higher IRF denial rates, including Molina Healthcare and Highmark Health. Still, the number of IRF requests these plans received pale in comparison to the thousands received by UnitedHealth Group, Humana and CVS Health.
Are these denials appropriate?
OIG stressed that it cannot determine whether or not the care denials were appropriate. However, it did find that about a third of LTCH denials were overturned upon appeal, as were 43% of IRF denials.
Denial rates were especially high at the largest Medicare Advantage plans, reaching 69% for LTCH denials and more than 80% for IRF denials.
This could indicate that some requests were inappropriately denied. At best, even patients whose denials were eventually overturned experienced a delay in medical care.
Moreover, it's the wide variation in denials across Medicare Advantage plans that is troubling, the office said.
"Extremely high or low denial rates may indicate differences in [Medicare Advantage organization] policies or performance, such as how they interpret or apply coverage criteria," OIG wrote in the report. "In future work, OIG will conduct an in-depth review of a sample of case files to examine MAOs' processes for reviewing prior authorization requests for post-acute care."
Stemming LTCH, IRF denial rates
One denial rate driver could be the use of outside contractors, which CMS allows Medicare Advantage plans to use to process some prior authorizations. Notably, OIG found that one contractor, naviHealth, which is a subsidiary of UnitedHealth Group, had higher denial rates than other contractors or plans that review requests internally.
Additionally, the bulk of overturned denials stemmed from outside contractors, OIG said.
"One reason for the higher overturn rates of denials issued by contractors may be differences in policies or procedures between the parent company and its contractor, or differences in interpretation of CMS coverage rules," OIG wrote in its report.
Still, the office noted that CMS did not collect detailed, request-level prior authorization data, which OIG said could help the agency flag disparities in denial and overturn rates. OIG recommended that CMS begin collecting this more granular data.
Additionally, OIG recommended CMS take steps to assess the reasons behind variable LTCH and IRF denial and overturn rates across Medicare plans and contractors. OIG said CMS neither concurred nor disagreed with its suggestions.
Sara Heath is an executive editor at Xtelligent Healthcare Media, where she covers patient engagement, healthcare policy and health IT.
