OIG had in the past raised concerns that Medicare Advantage organizations’ (MAOs’) use of prior authorization can in some cases result in denials and delays in access to needed care for enrollees. MAOs that inappropriately deny care are not delivering the full value that taxpayers pay them to provide.
OIG released its report on June 8, 2026 entitled Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials in which it identified denials of prior authorization requests for post-acute care after a hospital stay as a particular area of concern. The report highlighted new analyses of denial and overturn rates of requests for admission to skilled nursing facilities (SNFs), which provide short-term skilled nursing and/or therapy services to help patients recovering from an illness, injury, or surgery.
OIG found that in June 2024, the 19 MAOs in its review collectively denied 12 percent of requests for SNF admission. MAO denial rates ranged from 23 percent to 0.4 percent.
Enrollees and their providers appealed 18 percent of SNF denials. When SNF denials were appealed, MAOs overturned 95 percent in favor of the enrollee. The extremely high overturn rate indicates that some enrollees were initially denied medically necessary care and raises concerns about denials that were not appealed.
The MAO contractor naviHealth processed half of all requests for SNF admission and denied 14 percent of them—a higher denial rate than MAOs that processed requests internally (11 percent) and other contractors (9 percent). MAOs later overturned 97 percent of SNF denials issued by naviHealth when enrollees appealed. This raises concerns about whether contractors are receiving appropriate training and oversight from MAOs. NaviHealth is a subsidiary of the MAO United Health Group, Inc.
MAOs and their contractors denied requests for SNF-level care from nursing home residents 40 percent of the time, a much higher rate than requests from all other enrollees (11 percent).
The OIG report concluded and recommended:
More than half of people with Medicare were enrolled in Medicare Advantage in 2024, and MAOs received an estimated $494 billion to cover at least the same services as original Medicare for these enrollees. MAOs are expected to implement critical program controls to avoid unnecessary costs and ensure program integrity while at the same time ensuring that enrollees can get necessary and appropriate care. However, our findings show patterns of denial and appeal outcomes for SNF-level care that raise concerns.
The high concentration of enrollees in a few large MAOs, and the use of contractors to process prior authorization requests, means that the policies and performance of a few companies can impact care for millions of people. Overall, MAOs denied 12 percent of requests for SNF admission in June 2024 (approximately 13,500 of 109,400 requests). However, across MAOs, people living in nursing homes were denied SNF-level care 40 percent of the time. When enrollees appealed (18 percent of SNF denials), MAOs nearly always overturned the denial, particularly among the larger MAOs and MAO contractors. The high overturn rates raise concerns that some enrollees may have been inappropriately denied access to SNF-level care at their first request. These findings warrant further scrutiny from CMS.
As enrollment in Medicare Advantage continues to grow, so does the urgency and importance of ensuring that MAOs are delivering on the value that the Federal Government pays them to provide. Given OIG’s body of work that has raised concerns about enrollee access to care in Medicare Advantage, CMS should collect more comprehensive data to efficiently and effectively identify MAOs with problematic patterns of denials and take action as appropriate.
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