The Department of Health and Human Services Office of Inspector General (HHS OIG) has
shared a report on the Medicare Advantage Organizations’ (MAO) use of prior authorization for long-term acute care hospitals (LTCH) and inpatient rehabilitation facilities (IRF). This report builds off of OIG’s
previous work on denials of prior authorization requests, in which OIG identified denials for post-acute care as a “particular area of concern.”
The American Medical Rehabilitation Providers Association (AMRPA) met with OIG and provided background as part of this key follow-up report. As part of its newest audit, OIG reviewed approximately 3,200 prior authorization requests for LTCH admissions and 19,400 requests for IRF admissions from 19 MAOs in June 2024. The 19 MAOs had 29.3 million people enrolled in their MA contracts, which represented 86% of total MA enrollment. Among the key findings, OIG found that MAOs denied on average 43% of IRF admission requests, with UnitedHealth posting a 66% denial rate. Upon appeal, OIG found that MA plans collectively overturned nearly half (43%) of IRF denials, with some plans reporting an overturn rate as high as 86%.
OIG concludes that these rates “raise concerns that some enrollees may not be receiving services that MAOs are required to provide” and that, “as enrollment in Medicare Advantage continues to grow, so does the urgency and importance of ensuring that MAOs are delivering on the value that the Federal Government pays them to provide.”
