A survey conducted by the American Health Care Association (AHCA) found that Medicare Advantage (MA )plans are denying or delaying medically necessary post-acute care, often against medical professionals’ recommendations, on a daily and weekly basis. The survey was conducted by the AHCA in May 2025 and involved 363 nursing home providers.
The AHCA stated in a press release announcing its findings from the survey:
Denials or delays of medically necessary post-acute care by Medicare Advantage occur daily and/or weekly for two-thirds of skilled nursing providers.
- Providers report denials or delays of post-acute care services:
- Weekly (37 percent)
- Daily (29 percent)
- Monthly (17 percent)
The majority of providers have encountered situations in which a resident’s coverage is pulled prematurely against the advice of the resident’s medical care team:
- More than two-thirds (67 percent) of providers have encountered situations in which a MA plan pulled coverage for a resident against medical advice.
More than half of providers report that denials for care are frequently overturned once appealed, indicating a flawed or unfounded initial denial.
- Providers report that initial claims denials are reversed upon appeal always (3 percent) or sometimes (54 percent) compared to rarely (32 percent).
Here are three representative responses to the survey:
“We had a resident who was given 8 days of SNF from their MA, they went home after they were denied any further coverage and ended up back in the hospital within a week with a fracture from a fall at home.”
“Often, we see a resident’s stay cut short prematurely, leaving them with a tough decision to make. Pay out of pocket, or discharge home with the risk of ending up back in the hospital. It makes our job extremely challenging to give a resident the care they deserve knowing they can be cut by insurance at any time.”
“This just recently happened. A resident was getting ready to discharge home and two weeks before the discharge date, the MA plan pulled coverage. We had to challenge and the decision was reversed, but it created unneeded
angst for the resident and their family.
The president and CEO of AHCA stated in the press release: “This constant hoop jumping is resulting in too many skilled nursing patients being discharged too soon against medical advice, threatening their recovery. We want to make sure Medicare Advantage plans are providing the therapy benefits our seniors were promised and are not leaving important—sometimes life-saving—medical decisions to AI or insurers without appropriate guardrails and oversight. There is a better way to approach coverage decisions: where we put patients and their care team at the center of every decision.”
“Seniors deserve access to timely and medically-necessary post-acute care services. AHCA is calling on insurers and policymakers to put the power of care decisions into the hands of medical professionals and patients. Congress and the Centers for Medicare and Medicaid Services should continue to evaluate and reform Medicare Advantage plans to ensure that Medicare Advantage enrollees receive timely, uninterrupted, and clinically appropriate care.”
If you or a loved one may have been injured (or worse) as a result of malpractice in a nursing home in the United States due to nursing home staff shortage, nursing home understaffing, nursing home pressure ulcer (nursing home bedsore), a nursing home infection, nursing home fall, nursing home aspiration, nursing home neglect, nursing home negligence, nursing home abuse, or the nursing home failing to properly care for a vulnerable adult, you should promptly find a nursing home malpractice lawyer who may investigate your nursing home malpractice claim for you and represent you or your loved one in a nursing home malpractice case, if appropriate.
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