Federal Watchdog Finds Medicare Advantage Plans Reversed 95% of Nursing Home Denials on Appeal

Medicare Advantage enrollees who needed a skilled nursing facility bed after a hospital stay were denied coverage 12 percent of the time last June -- and when they appealed those denials, the insurer reversed course 95 percent of the time. That's the core finding in a pair of reports released June 11 by the Office of Inspector General at the U.S. Department of Health and Human Services.

The numbers matter because they suggest the "no" wasn't really a clinical judgment. It was a starting position.

"The extremely high overturn rate indicates that some enrollees were initially denied medically necessary care," the OIG report states, according to a summary reviewed by the Medicare Rights Center. The watchdog added that it's especially worried about the much larger group of patients whose denials were never appealed at all.

The scope of the review was large. According to the HHS OIG report posted on oig.hhs.gov, OIG reviewed prior authorization data from 19 Medicare Advantage parent companies covering 29.3 million enrollees -- roughly 86 percent of total Medicare Advantage enrollment -- for the single month of June 2024. Of about 109,400 requests for skilled nursing facility admission, insurers denied approximately 13,500. Only 18 percent of those denials were ever appealed. Of the appeals that were filed, plans overturned 2,313 of 2,445 denials in the enrollee's favor, a rate of 95 percent, according to Healthcare Finance News.

The three largest insurers by enrollment -- UnitedHealth Group, Humana, and CVS Health -- logged some of the highest denial rates for post-acute care, including skilled nursing, long-term acute care hospitals, and inpatient rehabilitation, according to the companion OIG report also released June 11. The Washington Post reported that CVS Health denied 80 percent of requests for long-term hospital care. For enrollees at those price points, the stakes are steep. Long-term acute care hospitals cost an average of roughly $49,000 per stay in 2023, according to NBC News coverage of the reports, while inpatient rehabilitation facilities ran about $24,000.

A third-party contractor added another layer of concern. According to the American Hospital Association's summary of the reports, naviHealth, a subsidiary of UnitedHealth Group, processed half of all skilled nursing facility admission requests and denied 14 percent -- a higher rate than both internal MAO review (11 percent) and other contractors (9 percent). When those naviHealth denials were appealed, insurers reversed 97 percent of them.

The timing issue alone should concern hospitalists and discharge planners. According to findings covered by the AHCA/NCAL, enrollees who appealed a skilled nursing facility denial waited a median of six days for a decision, with 17 percent of appeals taking 10 days or longer. For a 78-year-old recovering from hip surgery, six days in a hospital bed waiting to find out if you're allowed to go to rehab isn't a policy abstraction. It's a delayed recovery, and often a longer hospital stay -- which costs the system money while it costs the patient function.

The OIG also flagged a sharp disparity for people who already live in nursing homes. Long-stay nursing home residents faced a 40 percent denial rate for skilled nursing-level care, compared to 11 percent for other enrollees, according to Skilled Nursing News.

For-profit status tracked with denial rates. The report noted that denial rates were generally higher among for-profit Medicare Advantage contracts than nonprofit contracts, raising questions about whether financial incentives were shaping clinical gatekeeping decisions, according to reporting reviewed from Skilled Nursing News.

Meredith Freed, senior policy manager for Medicare policy at KFF, a nonpartisan health policy research group, told NBC News that while some prior authorization denials stem from documentation errors on the provider side, the unusually high denial rates in the HHS report "seem to undercut that point."

CMS acknowledged the reports but, according to oig.hhs.gov, did not explicitly concur or nonconcur with the OIG's recommendations, which include routine collection of request-level prior authorization data and a formal review of denial-rate variation across insurers and contractors. A data collection pilot launched in February 2026 that collects service-level prior authorization data from participating plans, according to Healthcare Finance News, but the OIG's recommendations call for more systematic action.

The broader pattern here isn't new -- prior OIG work in 2021 and 2022 found similar dynamics, with high overturn rates among the small share of patients who appealed. What this report adds is scale, specificity, and the names of the largest players on the wrong end of the numbers.

Sources cited:
- HHS Office of Inspector General (oig.hhs.gov) -- SNF admissions report (https://oig.hhs.gov/reports/all/2026/medicare-advantage-organizations-overturned-nearly-all-appealed-prior-authorization-denials-for-skilled-nursing-facility-admission-raising-concerns-about-initial-denials/)
- HHS Office of Inspector General (oig.hhs.gov) -- LTCH and IRF denials report (https://oig.hhs.gov/reports/all/2026/the-three-largest-medicare-advantage-organizations-denied-requests-for-long-term-acute-care-and-inpatient-rehabilitation-at-some-of-the-highest-rates/)
- Healthcare Finance News (https://www.healthcarefinancenews.com/news/medicare-advantage-organizations-overturned-most-snf-denials-oig-finds)
- NBC News (https://www.nbcnews.com/health/health-news/medicare-advantage-plans-denied-prior-authorization-requests-unusually-rcna349467)
- The Washington Post (https://www.washingtonpost.com/health/2026/06/11/elderly-medicare-advantage-patients-were-denied-care-high-rates-report-says/)
- Medicare Rights Center (https://www.medicarerights.org/medicare-watch/2026/06/11/medicare-advantage-plans-often-inappropriately-deny-access-to-skilled-nursing-care)
- American Hospital Association (AHA News) (https://www.aha.org/news/headline/2026-06-11-hhs-oig-reports-highlight-ma-insurer-denials-long-term-care-rehab-services-and-snf-admissions)
- Skilled Nursing News (https://skillednursingnews.com/2026/06/oig-findings-on-medicare-advantage-denials-of-nursing-home-care-renew-calls-for-meaningful-penalties/)
- PALTmed (https://paltmed.org/news-media/oig-report-finds-medicare-advantage-plans-overturned-95-appealed-snf-admission-denials)
- Healthcare Dive (https://www.healthcaredive.com/news/medicare-advantage-prior-authorization-denials-hhs-oig-post-acute-care/822724/)