LeadingAge and our Post Acute Care (PAC) Coalition partners asked the Office of the Inspector General (OIG) to take a closer look at Medicare Advantage Organizations’ (MAOs) prior authorization decisions in post acute care because we felt that prior analyses of all prior authorization requests did not reflect the experience of PAC providers. In response, on June 11, 2026, OIG issued not one but two reports—one on Skilled Nursing Facility (SNF) admissions and a second examining Inpatient Rehabilitation Facilities (IRFs) and Long Term Acute Care Hospitals (LTCHs). These findings show alarming rates of denials and high rates of success for beneficiaries on appeal, indicating that the initial decisions were often wrong and that care was unnecessarily delayed.

For this study, OIG looked at one month of data (June 2024) for 19 MAOs who cover 86% of all MA enrollees. They found MAOs denied 12% of initial prior authorization requests for SNF admissions, with wide variation across plans from 0.4% – 23% of requests for SNF care denied. For profit health plans denied at higher rates(13%) than non-profits (8%). Only 18% of denials were appealed but of those appealed, 95% were overturned, indicating many initial denials were likely inappropriate. Appeal decisions took on average 6 days from request to decision but some (17%) to 10 days or more to receive a decision. Meanwhile, the individual sits in the hospital waiting to transition.

LeadingAge heard from members that they were seeing an increasing number of individuals who are long-stay nursing home residents denied SNF admission. We asked OIG to determine if this was more widespread and they found that long-stay nursing home residents are denied SNF admission 40% of the time compared to all other MA enrollees who were denied 11% of the time.

Some MAOs indicated that they felt an appropriate alternative was for these individuals to return to their long-stay nursing home and receive intermittent skilled nursing services and/or outpatient therapies instead. This is likely because it would cost the plan less money than a SNF stay, which is entirely Medicare funded. Other MAOs suggested that individuals at a nursing home level of care may have conditions so severe including cognitive impairments that they would not be able to “meaningfully participate” in daily skilled therapies. MAOs often hire contractors to process prior authorization requests. Half of all SNF prior authorization requests were processed by naviHealth, one of these contractors owned by United Health Group, Inc. but used by numerous MAOs.  This company uses an algorithm to determine prior authorizations and the duration of a SNF stay.

LeadingAge has routinely raised concerns about third-party algorithms or artificial intelligence tools, such as those being used by naviHealth, to determine eligibility for services and the duration of these services.

The OIG report notes that naviHealth denied SNF care at higher rate(14%) than MAO’s internal teams (11%) or other contractors (9%). But more troubling is that naviHealth and contractor denials were overturned on appeal 97% of the time by the MAO. This can only call into question why plans are permitted to continue to use third parties to make prior authorization decisions when their algorithm or AI tools get the decision wrong with this level of frequency.

The Centers for Medicare and Medicaid Services (CMS) has said the MAOs are responsible for their contractors following the Medicare and Medicare Advantage regulations. This report underscores the need for greater MAO accountability for following the rules and ensuring that their contractors are also applying the rules accurately. OIG believes its findings warrant further scrutiny by CMS and outlines a series of recommendations to address the breakdowns in the system and urges CMS to collect more comprehensive data to identify problematic denial patterns and correct them.

LeadingAge has also been advocating for more detailed data collection on prior authorizations, which we believe will result in greater transparency and accountability. According to OIG, CMS neither concurred or did not concur with its recommendations. Therefore, it remains unclear what changes we might see result from this report. OIG however, indicated it will pursue future work digging deeper into these issues through “an in-depth review of a sample of case files to examine MAOs’ processes for reviewing prior authorizations requests for post-acute care.”  We applaud their pursuit of answers.

While these findings are disturbing because they translate into wrongfully denied or delay care for older adults, the report provides an unbiased analysis of the facts on the ground and raises numerous questions that both CMS and Congress must address.  It also helps to bolster our arguments for change.

The reports underscore there is a problem with prior authorizations in post-acute care.  As we note in our Fulfilling the Promise: Medicare Advantage white paper,  MA plans are obligated to cover all Medicare-covered services and cannot impose barriers that restrict access to medically necessary care. The coverage they provide must be at least equivalent to traditional Medicare but can be more generous. This OIG report demonstrates that MAOs are still missing the mark and not fulfilling the promise.

We will continue to advocate for MA plans to follow the Medicare rules related to coverage for SNF and home health services. We will continue to ask CMS to standardize the prior authorization requests across plans to ensure consistent application of Medicare rules in MA and to make it easier for those requests to contain all needed documentation upon submission. Further, we will continue to advocate for PAC prior authorization requests and appeals be expedited and decisions not delayed. Finally, this report only touches on initial prior authorizations and doesn’t even touch the subsequent requests to continue care that our SNFs must submit (on average 2-4 additional requests per episode).  Given the volume of requests, CMS must ensure that PAC providers are part of the interoperability and prior authorization solutions they are implementing to reduce provider burden and speed prior authorization decisions.