HHS Inspector General Report Shows Wide Variation in Medicare Advantage Prior Authorization Denials
A Department of Health and Human Services audit found that UnitedHealthcare, CVS Health and Humana denied prior-authorization requests for long-term care and rehabilitation services at rates up to 70%, while appeals reversed most denials.
The Department of Health and Human Services’ Office of the Inspector General released two reports on Thursday showing that Medicare Advantage plans denied prior-authorization requests for long-term acute care, inpatient rehabilitation and skilled-nursing facility services at rates that varied dramatically across insurers. Data from June 2024 covering 19 plans indicated that UnitedHealthcare, CVS Health and Humana rejected more than 70% of such requests for certain services, while other insurers denied as few as 8% of requests.
When patients appealed the denials, plans reversed 95% of them, prompting concerns about the initial decision-making process. "We’re looking at an extremely high overturn rate," said Rosemary Bartholomew, the lead author of the reports, adding that the pattern suggests a breakdown at the first request step.
The findings arrive as Health Secretary Robert F. Kennedy Jr. pushes reforms to streamline prior-authorization rules. Earlier this year, the administration secured commitments from major insurers to reduce the number of services subject to pre-approval, and industry group AHIP reported an 11% cut in prior-authorizations across several medical categories.
Medicare Advantage plans, which receive a fixed government payment per enrollee, can lower costs by using prior authorization. Critics argue that the high denial rates may reflect profit-driven decisions rather than medical necessity. "These denial rates reinforce concerns that healthcare decisions are being made with profit rather than medical necessity in mind," said Miranda Yaver, an assistant professor of health policy.
Insurers maintain that prior authorization prevents unnecessary care. A CVS Health (Aetna) spokesperson said the company reviews requests promptly and offers a clear appeals process. UnitedHealthcare and Humana did not respond to comment requests.
Policy analysts noted that some denials stem from administrative errors by providers, but the unusually high rates observed in the HHS report raise questions about systemic issues. The inspector general’s office recommended that the Centers for Medicare & Medicaid Services collect prior-authorization data more regularly and investigate the variation in denial rates across insurers.
