June 15, 2026
The Department of Health and Human Services Office of Inspector General (OIG) released a report examining Medicare Advantage Organizations (MAO) prior authorization denials for skilled nursing facility (SNF) admissions. OIG reviewed prior authorization data from 19 MAO parent companies covering 29.3 million enrollees, about 86 percent of total Medicare Advantage enrollment, for June 2024.
The 19 MAOs collectively denied 12 percent of SNF admission requests, with denial rates ranging from 0.4 percent to 23 percent across plans. Enrollees and providers appealed 18 percent of denials; when appealed, MAOs overturned 95 percent in the enrollee's favor. OIG stated that the extremely high overturn rate indicates some enrollees were initially denied medically necessary care and raises concerns about denials that were never appealed.
OIG recommended that CMS regularly collect request-level prior authorization data, including service type and contractor information; address breakdowns in initial reviews that drive the high overturn rate; assess variation in denial rates across MAOs and contractors; and assess differences in denial rates between nursing home and non-nursing home residents. CMS did not explicitly concur or nonconcur with the recommendations.
The full report is available on the OIG website.