Federal investigators say one of the country’s largest Medicare Advantage insurers denied 71 percent of seniors’ requests for long-term hospital-level care, a rate far higher than many smaller competitors. That finding, tied to UnitedHealth’s Medicare Advantage business, lands as Washington intensifies scrutiny of how private plans handle care for frail older adults leaving the hospital. For families counting on post-acute care to recover, the numbers translate into real decisions about whether a loved one goes home or gets the extended treatment doctors recommend.
Why UnitedHealth’s denial rate matters right now
The Office of Inspector General for the Department of Health and Human Services, through its Office of Evaluation and Inspections, examined how Medicare Advantage plans handled requests for long-term acute care hospitals and inpatient rehabilitation facilities in report OEI-09-24-00330. The evaluation, presented as an official data brief, found that the three largest Medicare Advantage organizations denied these requests at some of the highest rates in the program, and that UnitedHealth’s rate reached 71 percent according to OIG’s evaluation.
These services are not routine. Long-term acute care hospitals and inpatient rehabilitation facilities are typically reserved for seniors who are too sick or too weak to go straight home after a hospital stay. When a plan denies authorization for this level of care, families may have to scramble for alternatives, accept shorter stays in less intensive settings, or pay out of pocket. The OIG data brief flags that such denials can affect access to medically necessary care and calls on the Centers for Medicare & Medicaid Services, or CMS, to address the incentives and contractor practices that may be driving high denial rates.
The stakes are heightened because Medicare Advantage plans make a large volume of prior authorization decisions. CMS has reported that Medicare Advantage insurers made nearly 53 million prior authorization determinations in a single year, according to agency monitoring data on prior authorization initiatives. When denial rates are high for a vulnerable group like seniors needing long-term acute or rehabilitation care, even a small share of questionable decisions can affect thousands of people.
The evidence behind the 71 percent denial figure
The 71 percent figure comes from OIG’s evaluation of UnitedHealth as part of OEI-09-24-00330, which focused on the three largest Medicare Advantage organizations and compared them with other plans. The report describes itself as an Evaluation/Data Brief and explains that OIG analysts reviewed prior authorization decisions for long-term acute care hospitals and inpatient rehabilitation facilities. The investigators concluded that these large organizations denied requests for long-term acute care and inpatient rehabilitation at some of the highest rates in Medicare Advantage, according to the same OIG data brief.
OIG has been building this record for several years. In an earlier evaluation, report OEI-09-18-00260, OIG physicians reviewed a sample of prior authorization denials across Medicare Advantage plans and found that some denied requests actually met Medicare coverage rules and would likely have been approved under Original Medicare, according to the agency’s 2022 evaluation. That earlier work highlighted post-acute facility stays among the services where denials raised concerns about access to medically necessary care.
OIG has also looked at what happens when beneficiaries challenge denials. In report OEI-09-24-00331, the inspector general’s office examined prior authorization denials for skilled nursing facility admissions and found that Medicare Advantage organizations overturned nearly all denials that were appealed. The high overturn rate raised questions about whether the initial denials were appropriate, according to the agency’s findings on skilled nursing facility appeals.
Congress has taken notice. A Majority Staff report from the U.S. Senate Permanent Subcommittee on Investigations examined internal practices at UnitedHealthcare, Humana, and CVS/Aetna, focusing on how these Medicare Advantage insurers handled post-acute care requests. The staff described strategies that, in their view, contributed to denials and automation of utilization management, according to the PSI Majority Staff report. That congressional work relied in part on OIG’s findings and added internal documents from the insurers to the public record.
What remains unresolved and what to watch next
Even with OIG’s evaluations and the Senate investigation, several key questions remain open. The OIG data brief on long-term acute and inpatient rehabilitation care identifies high denial rates and points to incentives and contractor-driven decision making, but it does not spell out how many individual patients were affected or how outcomes differed for those whose requests were denied. The Senate Majority Staff report adds allegations about internal strategies at UnitedHealthcare, Humana, and CVS/Aetna, yet it does not represent a final regulatory or legal finding.
There is also uncertainty about how quickly CMS will respond. OIG’s long-term care data brief includes recommendations for CMS to examine plan incentives and oversight related to denials, and the skilled nursing facility report urges stronger monitoring of prior authorization contractors. The latest publicly available updates are from these OIG reports and the Senate investigation, so the current status of any CMS enforcement or rule changes tied specifically to the 71 percent denial figure is not yet clear based on the record cited here.
For seniors and families, the practical takeaway is to treat prior authorization decisions as contestable rather than final. OIG’s finding that Medicare Advantage organizations overturned nearly all appealed denials for skilled nursing facility admission suggests that appeals can succeed when beneficiaries or their representatives challenge an initial “no.” When a plan denies long-term acute, inpatient rehabilitation, or skilled nursing facility care, the first step is to request the denial letter, review the stated reason, and consider filing an appeal using the plan’s instructions and any supporting documentation from clinicians.
Advocates and policymakers will be watching whether CMS uses its oversight tools to push UnitedHealth and other large Medicare Advantage organizations to change how they handle long-term care requests. With nearly 53 million prior authorization determinations made by Medicare Advantage insurers in a single year, according to CMS monitoring data, even incremental improvements in how plans evaluate post-acute care could affect access to recovery for a large share of older Americans.
