Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Government Watchdog Agency Finds Excessive Medicare Advantage Denials of Care

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The Office of Inspector General (OIG) of the Department of Health and Human Services released two reports on June 11, 2026 that explore Medicare Advantage organizations’ (MAOs’) denials of prior authorization for post-acute care after a hospital stay. This builds off a 2022 OIG report finding that Medicare’s annual audit of Medicare Advantage (MA) plans “have highlighted widespread and persistent problems related to inappropriate denials of services and payment.” The two 2026 reports:

OIG Findings

In the report assessing Medicare Advantage organizations (MAOs) denial of skilled nursing facility (SNF) care, OIG found:

  • “In June 2024, the 19 MAOs in this 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 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).”

In the report assessing variations in MAO denial and overturn rates concerning long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs), OIG found:

  • “Among the 19 MAOs in this review, the 3 largest MAOs by enrollment denied prior authorization requests for care in LTCHs and IRFs at higher rates than most of their peers in June 2024.
  • When enrollees appealed, MAOs collectively overturned 36 percent of LTCH denials and 43 percent of IRF denials, indicating that some enrollees were initially denied medically necessary care. Some MAOs had much higher overturn rates than their peers. For example, IRF overturn rates ranged by MAO from 14 percent to 86 percent.
  • In some cases, high denial rates were driven by contractors that denied prior authorization requests on behalf of the MAOs, many of which were later overturned on appeal by the MAO. This raises concerns about whether contractors are receiving appropriate training and oversight from MAOs.”

A STAT News article titled “Private Medicare plans erect barriers to rehab care in pursuit of profit, federal investigators find” by Casey Ross and Bob Herman (June 11, 2026) summarizes the OIG reports:

The nation’s dominant Medicare Advantage insurers denied rehabilitative care for older and disabled Americans at higher rates than industry peers, then frequently overturned those denials when patients appealed, federal investigators found. The pattern reinforces longstanding concerns that insurers like UnitedHealth Group and Humana are profiting by forcing seriously ill and injured adults 65 and older to fight for care recommended by their doctors.

Highlighting the impact on MA enrollees, the article notes that:

Only a fraction of patients appeal the rejections, suggesting the biggest Medicare Advantage insurers are erecting unjustified barriers to care for enrollees — many of whom do not have the time, energy, or resources to fight back.

Reflecting on these MA plan practices which were also the subject of earlier STAT News series, Ross and Herman state:

Beyond corroborating a mechanistic denial-and-overturn pattern, the reports spotlight the profit-seeking tactics that have become hardwired into Medicare Advantage, the predominant source of health insurance for Medicare beneficiaries.

Conclusion

These OIG reports confirm what the Center for Medicare Advocacy (CMA) has witnessed for years concerning MA enrollees’ barriers to accessing medically necessary care.  As outlined in a recent CMA issue brief titled “Premature Terminations of Coverage by Medicare Advantage Plans” (April 2026), a related problem arises when care is initially authorized by an MA plan but terminated before it is clinically appropriate to do so.  As outlined in the issue brief, some important but incomplete steps to address MA prior authorization abuses were taken in the last Administration. In June 2025 the current administration announced a series of voluntary (and unenforceable) commitments that certain representatives of the insurance industry pledged to take to address some of the problems with prior authorization across different types of health coverage. However, as noted by some commenters, many of these reforms were already required in Medicare Advantage.  It is long past due for policymakers to take meaningful action, with enforceable plan requirements to curb MA plan abuses and adequately protect plan enrollees.

June 11, 2026 – D. Lipschutz