Federal investigators find Medicare Advantage plans deny rehabilitation care at high rates, often reversing denials on appeal
Federal investigators reported that major Medicare Advantage insurers including UnitedHealthcare, CVS Health, and Humana denied requests for rehabilitation and nursing home care at unusually high rates, with denial rates ranging from 8% to 80% depending on the company. The insurers reversed approximately 95-97% of these denials when patients appealed, suggesting the initial denials often lacked merit. The findings raise concerns about whether profit motives are driving healthcare decisions that delay or prevent necessary care for seniors and disabled Americans.
The Office of Inspector General for the Department of Health and Human Services released reports examining prior authorization denials for rehabilitation services among Medicare Advantage plans in June 2024. The investigation found that major insurers denied requests for services like skilled nursing facility care and inpatient rehabilitation at rates far exceeding industry peers, with some companies rejecting over 70% of requests. However, when patients appealed these denials, the insurers reversed them at rates of 95-97%, indicating the initial denials often did not withstand scrutiny. The reports specifically examined 19 Medicare Advantage groups and found significant variation in denial rates, with UnitedHealthcare, CVS Health, and Humana showing the highest rates. These findings underscore longstanding concerns that Medicare Advantage plans, which receive fixed government funding per patient and profit by keeping costs low, use prior authorization as a cost-containment tool that may prioritize financial considerations over medical necessity.
How coverage differed
STAT News emphasizes the role of UnitedHealth's NaviHealth subsidiary and references its prior investigative reporting, while NBC News provides broader context about prior authorization reform efforts and quotes from HHS officials and health policy experts. The NYT headline is more concise and neutral. All three sources report the same core findings but with different emphasis and depth.
What different sources said
- NBC NewsLeft
Medicare Advantage plans denied prior authorization requests at unusually high rates, HHS report finds
- NYT PoliticsLeft
Medicare Advantage Plans Often Deny Seniors Access to Special Care, Analysis Shows
- STAT NewsCenter
STAT+: Private Medicare plans erect barriers to rehab care in pursuit of profit, federal investigators find
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