Medicare Denials Soar: Insurers Reject Critical Care

A Department of Health and Human Services inspector general report revealed that Medicare Advantage plans are denying patients essential rehabilitation and other critical services at unusually high rates. These denial rates are staggering, with variations from 8% up to 80% for long-term care services by company. This situation is particularly concerning given that 95% of prior authorization denials were overturned when patients appealed, suggesting initial rejections may not be based on medical necessity. The investigation examined requests in June 2024 across 19 Medicare Advantage groups, finding that major insurers like UnitedHealthcare, CVS Health, and Humana exhibited the highest denial rates for costly services such as long-term acute care and inpatient rehabilitation. These services are crucial for patients recovering from serious conditions like strokes or severe fractures. Experts suggest that for-profit insurers are more likely to deny prior authorization requests than nonprofit insurers. The Centers for Medicare & Medicaid Services has been recommended to collect prior authorization data more regularly to investigate the widespread nature of this issue and the significant variation in denial rates among different insurers. While insurers argue prior authorization controls healthcare costs, the high overturn rate raises serious concerns about patient access to necessary care and potential profit motives influencing coverage decisions. Health Secretary Robert F. Kennedy Jr. has committed to reforming prior authorization rules to streamline processes and reduce unnecessary preapprovals.