06/11/2026
The Office of Inspector General (OIG) conducted a new federal study that was published 6/11/26 on their Website, Previous OIG work identified concerns that Medicare Advantage organizations’ (MAOs’) use of prior authorization can, in some cases, lead to denials and delays in access to necessary care for enrollees. When care is inappropriately denied, MAOs are not delivering the full value paid for by taxpayers.
OIG identified prior authorization denials for post-acute care following a hospital stay as a key area of concern. This report presents new analysis of denial and overturn rates for admissions to skilled nursing facilities (SNFs), which provide short-term skilled nursing and therapy services to support recovery after illness, injury, or surgery.
When enrollees and their providers appealed 18 percent of SNF denials, MAOs overturned 95 percent in favor of the enrollees. The extremely high overturn rate suggests that some enrollees were initially denied medically necessary care, raising concerns about denials that were never appealed.
The MAO contractor naviHealth, a subsidiary of United Health Group, http://Inc., processed approximately half of all SNF admission requests and denied 14 percent—higher than MAOs that handled requests internally (11 percent) and other contractors (9 percent). However, MAOs later overturned 97 percent of naviHealth’s denials upon appeal, raising concerns about the adequacy of contractor training and oversight.
MAOs and their contractors denied SNF-level care requests from nursing home residents 40 percent of the time, significantly higher than the 11 percent denial rate for all other enrollees.
For more information and to access the report, click on the link here: Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials, OEI-09-24-00331 The Office of Inspector General (OIG) conducted a new federal study that was published 6/11/26 on their Website (https://hubs.li/Q04l3dzD0).
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