Patients enrolled in some of the nation’s largest Medicare Advantage plans were denied requests for rehabilitation and other critical services at unusually high rates, according to a report released Thursday by the Department of Health and Human Services’ inspector general.Subscribe to read this story ad-free Get unlimited access to ad-free articles and exclusive content.It comes amid increased scrutiny of how insurers use prior authorization, a cost-cutting tool that experts say often leads to the delay or denial of necessary care.“These denial rates are quite staggering,” said Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh.“It’s another data point that reinforces what a lot of Americans have already been articulating a lot of frustration about — which is that healthcare decisions are being made with profit rather than medical necessity in mind.” Erin Bliss, an assistant inspector general at HHS, said she was surprised by the findings.
“The range of denial rates from 8% all the way up to 80% by company for long-term care, that’s a pretty shocking variation,” she said.A second report, also released Thursday, focused on prior authorization requests for skilled nursing facility care.It found that when patients appealed, plans reversed 95% of denials.“We’re looking at an extremely high overturn rate,” Rosemary Bartholomew, the lead author of the reports, said.
“That really raises concerns that there’s a breakdown happening at that first request step.”Health Secretary Robert F.Kennedy Jr.
has vowed to take steps to reform prior authorization.Last year, Kennedy announced that the agency had secured commitments from several major health insurers to streamline prior authorization rules and reduce the number of services subject to preapproval.
In April, AHIP — an industry trade group that represents insurers — said leading health plans eliminated 11% of prior authorizations a...