Medicare Advantage plans denied prior authorization requests at unusually high rates, HHS report finds
A federal report found some major Medicare Advantage plans denied prior authorization requests for rehab and other care at unusually high rates.
Intelligence analysis by GPT-5.4 Mini
HHS inspectors found sharp variation in denial rates across Medicare Advantage insurers, including some that rejected more than 70% of requests for costly post-acute services. The report adds pressure on insurers and on federal officials pushing to rein in prior authorization delays.
A government report found some health plans for older people were saying “no” to doctor requests a lot more often than others. That matters because if a person needs rehab after being sick or hurt, a delay can be like blocking the only road to the hospital.
Analysis
What the report found
The Department of Health and Human Services’ inspector general reviewed prior authorization requests in June 2024 across 19 Medicare Advantage groups. It found unusually high denial rates for some expensive services, including long-term acute care and inpatient rehabilitation, which are often used after strokes, heart problems, or serious fractures.
The report said UnitedHealthcare, CVS Health, and Humana had the highest denial rates for those services, with some requests rejected more than 70% of the time. The article notes that nearly 20 million people in the U.S. are enrolled in Medicare Advantage plans managed by those three companies.
Why the denials matter
Prior authorization is meant to control costs, but critics say it can delay or block medically necessary care. Miranda Yaver of the University of Pittsburgh called the denial rates “quite staggering,” arguing they reflect frustration that insurance decisions are being made with profit rather than medical need in mind. Erin Bliss, an assistant inspector general, said the spread from 8% to 80% by company for long-term care was a major surprise.
A separate report released the same day found that when patients appealed denials for skilled nursing facility care, plans reversed 95% of them. That suggests many initial denials may not hold up under review.
What happens next
The inspector general wants CMS to collect prior authorization data more regularly and investigate the wide differences among insurers. Insurers still argue the process helps avoid unnecessary care, and Aetna said it reviews requests promptly and offers an appeals process. But the report points to a larger transparency problem: regulators say they do not currently have enough visibility into how often care is being denied.
Key points
- An HHS inspector general report found unusually high prior authorization denial rates in some major Medicare Advantage plans.
- The report highlighted long-term acute care and inpatient rehabilitation, services often needed after serious illness or injury.
- UnitedHealthcare, CVS Health, and Humana posted the highest denial rates for those services in the review.
- A companion report found that 95% of denials for skilled nursing facility care were overturned on appeal.
- The inspector general wants CMS to collect more data and examine why denial rates vary so widely.
If CMS starts collecting more data and investigating the biggest differences, the system could become more transparent and easier to fix. The 95% appeal reversal rate suggests that better first-step review could reduce unnecessary denials and speed up care.
If regulators do not get better visibility into denial patterns, high rejection rates could continue unchecked. Patients may keep facing delays, paying out of pocket, or settling for lower levels of care when treatment is most time-sensitive.
