The National Association of Long Term Hospitals (NALTH) has highlighted findings from a newly released report from the U.S. Department of Health and Human Services Office of Inspector General (OIG), which found that the nation’s three largest Medicare Advantage organizations (MAOs) denied requests for long-term acute care hospital (LTCH) and inpatient rehabilitation facility services at some of the highest rates within the Medicare Advantage program.

“The OIG report found that prior authorization requests for LTCH care were denied at exceptionally high rates, with Medicare Advantage plans denying nearly two-thirds of requests, on average,” NALTH documented in a press release.

The OIG initiated the review because prior OIG work raised concerns that Medicare Advantage organizations’ (MAOs’) use of prior authorization can, in some cases, result in denials and delays in access to needed care for enrollees, according to the report. “MAOs that inappropriately deny care are not delivering the full value that taxpayers pay them to provide.”

According to the report, out of the 19 MAOs reviewed, the three largest by enrollment rejected prior authorization requests for care in LTCHs and inpatient rehabilitation facilities (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, suggesting that some enrollees were initially denied medically necessary care, as noted by the OIG. Some MAOs had significantly higher overturn rates compared to others. For example, IRF overturn rates among different MAOs varied from 14 percent to 86 percent.

Additionally, in some instances, high denial rates resulted from contractors denying prior authorization requests on behalf of the MAOs, many of which were subsequently overturned on appeal by the MAOs.

OIG suggests that Congress and the Centers for Medicare & Medicaid Services (CMS) should:

• Routinely gather request-level prior authorization data, including service type and contractor details.
• Analyze the reasons behind the significant disparities in LTCH and IRF denial and overturn rates across MAOs and contractors, taking necessary actions.

“These findings confirm what LTCH providers, physicians, patients, and families have experienced for years: Medicare Advantage plans are too often standing between medically complex patients and the specialized care their physicians have determined they need,” said NALTH President Chris Fox in a statement. “When access to medically necessary LTCH care is delayed or denied, patients face longer recoveries and increased complications, and potentially worse outcomes.”

NALTH stated that it has repeatedly raised concerns with CMS about Medicare Advantage plans’ use of prior authorization and other utilization management practices to restrict access to LTCH care. “Despite recent statements by health plans that highlight improvements in reducing prior authorization denials, post-acute care providers have seen no appreciable improvement and some NALTH members have actually seen prior authorization levels worsen, resulting in decreased access to these critical services for our nation’s seniors. The consequences of these delays can be significant.”