OIG Raises Concerns About Medicare Advantage Prior Authorization in Post-Acute Care

A new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG) raised concerns about Medicare Advantage prior authorization practices in post-acute care. Among the findings, Medicare Advantage organizations (MAOs) overturned 95% of appealed denials for skilled nursing facility admissions, raising concerns that some beneficiaries may have been initially denied medically necessary care or faced delays in accessing care. OIG noted that the exceptionally high overturn rate raises concerns about denials that were never appealed. The agency recommended that CMS collect more detailed prior authorization data and evaluate differences among plans and contractors to identify problematic patterns. A companion OIG report found wide variation in denial rates across plans and contractors, including some of the highest denial rates among the three largest MAOs for long-term acute care hospitals and inpatient rehabilitation facilities.