Federal investigators raised concerns about how Medicare Advantage plans handle requests for post-hospital recovery care, finding that many denials were later overturned on appeal.
Two reports from the Office of Inspector General at the Department of Health and Human Services earlier this month found that Medicare Advantage insurers frequently denied requests for skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals. The reviews focused on some of the largest insurers in the program, including UnitedHealth Group Inc. (NYSE:UNH), Humana Inc. (NYSE:HUM) and CVS Health Corporation (NYSE:CVS).
One report found insurers denied about 13% of requests for skilled nursing facility care. About one in five patients appealed those denials, and nearly all were later approved. UnitedHealth, which handled the largest number of appeals, reversed 99.7% of its denials. Investigators said some initial denials may have resulted from incomplete medical records, but the high reversal rate suggested broader concerns about the review process. Because most patients never appealed, some may have gone home or missed specialized care altogether after receiving an initial denial.
