Medicare Advantage insurers denied long-term care authorizations at high rates, HHS inspector general reports

Why it matters locally: South Dakota has an aging population with higher-than-average Medicare Advantage enrollment; residents relying on these plans for long-term care services may face increased denials and delays in accessing nursing home and home health benefits.

The Department of Health and Human Services inspector general documented that three major Medicare Advantage insurers denied prior authorization requests for long-term care services at unusually high rates, according to a report released this week. UnitedHealthcare, CVS Health and Humana each showed denial rates that outpaced other carriers reviewed in the federal examination. The inspector general's office did not disclose the specific denial percentages for each insurer in its preliminary findings. Medicare Advantage plans require insurers to approve coverage for certain medical services before patients receive them through the prior authorization process. Long-term care services, which include nursing home and home health assistance for extended periods, represent a significant category of coverage requests. The report focused on how often insurers rejected these authorization requests compared to approval rates at other Medicare Advantage plans. Denials prevent beneficiaries from accessing covered services unless they challenge the decision through an appeals process. The inspector general's office did not announce enforcement actions or penalties against the three insurers at the time of the report's release. The examination came as federal regulators have increased scrutiny of Medicare Advantage denial practices in recent years, citing concerns about whether plans properly approve medically necessary services. Medicare Advantage plans, which serve more than 28 million beneficiaries, operate as an alternative to traditional Medicare. These private plans contract with the federal government to provide coverage and must follow federal rules governing medical necessity determinations and authorization timelines. The report added to existing concerns about prior authorization delays and denials in the Medicare Advantage program. Patient advocacy groups and medical associations have stated that extensive authorization requirements can delay care and burden healthcare providers with administrative tasks. UnitedHealthcare operates as a division of UnitedHealth Group, one of the nation's largest health insurance companies. CVS Health operates Aetna, which offers Medicare Advantage plans. Humana ranks among the largest standalone Medicare Advantage insurers by enrollment. The inspector general's office indicated it would continue monitoring denial patterns across Medicare Advantage plans. The agency did not specify whether it would conduct additional reviews of the three insurers or expand its examination to other plans.