A brand new report from the Workplace of Inspector Common revealed that the three largest Medicare Benefit insurers denied prior authorization requests for long-term acute care and inpatient rehabilitation at excessive charges in 2024.
The evaluation collected information from the 19 largest Medicare Benefit organizations for June 2024.
It discovered that long-term care hospital (LTCH) denial charges have been 80% in June 2024 for CVS Well being, 72% for Humana and 71% for UnitedHealth Group, in comparison with 42% for all different MA organizations. Inpatient rehabilitation facility denial charges have been 66% for UnitedHealth Group, 54% for Humana and 51% for CVS Well being, versus 41% for different MA teams.
When beneficiaries appealed denials, MA organizations overturned 36% of LTCH denials and 43% of inpatient rehabilitation denials. This means that “some enrollees have been initially denied medically mandatory care,” based on the report.
The OIG additionally discovered that typically, excessive denial charges have been as a consequence of contractors that denied prior authorization requests on behalf of MA organizations, and lots of have been finally overturned on attraction. That is an impartial third-party employed by a healthcare group to deal with prior authorizations.
“This raises considerations about whether or not contractors are receiving applicable coaching and oversight from [MA organizations],” the report said.
The OIG made a number of suggestions to CMS, similar to commonly accumulating prior authorization information that features service kind and contractor info. It additionally recommends assessing causes for the vast variation in LTCH and inpatient rehabilitation denial and overturn charges.
CMS didn’t “explicitly concur or nonconcur” with these suggestions, based on the report.
The report comes after a number of well being insurers made a sequence of commitments to enhance prior authorization, a few of which took impact at the start of 2026.
One Medicare Benefit advocacy group famous that the OIG’s information is outdated.
“This report displays information from 2024. Since then, well being plans have voluntarily eradicated roughly 6.5 million prior authorizations throughout markets — together with greater than 15 % in Medicare Benefit,” stated Mary Beth Donahue, president and CEO of Higher Medicare Alliance. “Prior authorization is a crucial instrument for protected, applicable, and reasonably priced care. We stay dedicated to working with policymakers to proceed bettering prior authorization, so choices are quicker, simpler, and extra correct for greater than 35 million Medicare Benefit beneficiaries.”
AHIP, a company representing payers, argued that the report omits key information.
“The experiences ignore critical, well-documented considerations about vast variations in the associated fee and high quality of post-acute care and expert nursing amenities. Greater than 35 million People actively select MA as a result of it supplies them with higher, extra reasonably priced care – together with serving to seniors transition to high-quality, clinically applicable care settings to help their rehab and restoration,” stated Chris Bond, AHIP spokesperson.
Picture: Piotrekswat, Getty Photographs
