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Medicare Advantage

Medicare Advantage Plans Reversed Nearly All Skilled Nursing Facility Denials on Appeal, OIG Finds

A federal audit of 19 Medicare Advantage organizations found they overturned 95 percent of denied prior authorization requests for skilled nursing facility stays when enrollees appealed, raising questions about the accuracy of initial decisions.

By the Goodsurance editorial teamOctober 11, 2026

The Office of Inspector General reviewed prior authorization activity for skilled nursing facility admissions across 19 Medicare Advantage organizations and found that when enrollees appealed a denial, plans reversed course 95 percent of the time in favor of the enrollee, according to a report issued in June 2026.

The 19 organizations collectively denied 12 percent of skilled nursing facility prior authorization requests reviewed during June 2024. Denial rates varied considerably across plans, ranging from 0.4 percent to 23 percent. naviHealth, a UnitedHealth Group subsidiary that processed roughly half of all skilled nursing facility requests in the study, denied 14 percent of those it handled. When enrollees appealed naviHealth-processed denials, the overturn rate reached 97 percent.

Medicare Advantage plans denied skilled nursing facility stays, then reversed 95 percent of those denials when members appealed. An OIG report raises questions about the accuracy of initial decisions.

A separate disparity emerged for enrollees who already resided in a nursing facility and were seeking an inpatient skilled nursing facility stay. That group faced a denial rate of 40 percent, compared with 11 percent for other enrollees.

OIG said the near-total reversal rate on appeal raises concerns that some initial denials may not have been clinically warranted. The watchdog recommended CMS examine the root causes of high overturn rates, assess the variation in denial rates across organizations and third-party vendors, and investigate the elevated denial rate faced by nursing facility residents. As of the report date, CMS had not acted on any of the three recommendations.

In plain words

A government watchdog studied 19 Medicare Advantage insurance plans. It looked at requests for people to move into a skilled nursing facility. When a plan said no, and the member appealed, the plan changed its answer 95 times out of 100. That means most of the first no answers may have been wrong. Denial rates also varied a lot from plan to plan, from less than 1 percent to 23 percent. People who already lived in a nursing home faced an even higher denial rate of 40 percent. The watchdog told Medicare to find out why so many first decisions get reversed on appeal. Medicare had not taken action on that advice yet.

Understand the basics first

Source: OIG
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