Design Highlights
- Medicare Advantage plans denied nearly 13% of requests for skilled nursing facilities, with some plans rejecting up to 86% of inpatient rehab requests.
- Denial rates among the largest insurers varied significantly, with some plans denying as low as 0.4% and others up to 23%.
- High appeal overturn rates indicate that initial denials for rehab care are often not justified, suggesting flaws in the assessment process.
- Denials can delay access to necessary rehab services, increasing risks of complications and mobility decline for seniors after surgeries or serious injuries.
- The use of prior authorization by Medicare Advantage plans creates additional barriers, unlike Original Medicare, which does not require it for skilled nursing admissions.
Medicare Advantage plans are playing a dangerous game, and seniors are the ones getting hurt. With around 35 million seniors relying on these plans, the patterns of denial for vital post-hospital rehab are alarming. Federal investigators uncovered that many requests for admission to skilled nursing facilities are turned down. This isn’t just a few isolated incidents; it’s a widespread issue affecting vulnerable people when they need care the most.
Medicare Advantage plans are denying essential post-hospital rehab, leaving millions of vulnerable seniors without necessary care when they need it most.
Imagine coming out of surgery or battling a serious illness, only to find that your insurer has decided you don’t need that skilled nursing facility. According to federal data, about 13% of requests for admission were denied.
By 2022, the three largest Medicare Advantage insurers were rejecting nearly one-quarter—yes, one-quarter—of all post-acute care requests. That’s not just a hiccup; it’s a full-blown crisis.
The denial rates are staggering. In June 2024, 19 plans denied 12% of requests for nursing and rehab facilities, with denial rates varying wildly. Some plans denied as little as 0.4%, while others shot up to a shocking 23%.
For inpatient rehab, the rates soared even higher, with one plan denying a jaw-dropping 86% of requests. UnitedHealthcare led the pack with a 64% denial rate. It begs the question: what kind of game are these insurers playing?
What’s worse? Nearly every appeal for rehab denials gets overturned. That’s right; Medicare Advantage insurers reversed their own nursing-home denials 97% of the time. So, what’s the deal with those initial denials? It seems they’re just tossing out “no” as a first response. This creates a frustrating cycle of stress and anxiety for seniors and their families, who are already dealing with enough.
Why does this matter? Denials can block access to necessary rehab after surgeries, strokes, or serious injuries. Skilled nursing and inpatient rehab are often the safest options when home care isn’t feasible. Delays in accessing this care can lead to complications, increased fall risks, and a decline in mobility. Yet, patients are often pushed toward outpatient care, even when that’s not what they need. Furthermore, Medicare Advantage plans sometimes deny coverage despite their own coverage policies, creating additional barriers for seniors seeking necessary care.
And let’s not forget the role of prior authorization. Insurers love to use it to control costs, but at what cost to patients? Senate investigators found that dominant Medicare Advantage insurers are denying rehabilitative care at higher rates than peers, effectively playing God with seniors’ health. Unlike Original Medicare coverage, which does not require prior authorization for skilled nursing facility admissions following a qualifying hospital stay, Medicare Advantage plans add layers of bureaucratic hurdles that delay critical care. It’s a mess, and the stakes couldn’t be higher.
