An HHS Office of Inspector General (OIG) report found that among 19 Medicare Advantage organizations, the three largest denied prior authorization requests for care in long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs) at higher rates than most of their peers.
"In some cases, high denial rates were driven by contractors that denied prior authorization requests on behalf of the MA organizations, many of which were later overturned on appeal by the [organization]," the investigators noted. "This raises concerns about whether contractors are receiving appropriate training and oversight from MA organizations."
Overall, the 19 plans in June 2024 denied 65% of LTCH prior authorization requests and 54% of IRF requests. For the LTCH requests, denial rates varied widely, with CVS Health denying 80% of 393 requests, while University of Pittsburgh Medical Center Health System denied 8% of 72 requests.
In terms of appeals, plans overturned 36% of LTCH denials on appeal, as well as 43% of IRF denials. Again, overturn rates varied widely; among LTCH appeals, for example, Elevance Health overturned 69%, while CVS Health overturned 10%. Among IRF appeals, Blue Cross Blue Shield of Michigan topped the list with an 86% overturn rate, while Humana overturned only 14%.
