UnitedHealth, Humana and CVS denied post-hospital care at some of the highest rates

The three largest Medicare Advantage insurers turned down requests for post-hospital care at some of the highest rates among major plans, a federal watchdog has found.

UnitedHealth Group, Humana and CVS Health, the parent company of Aetna, each denied many requests to move patients into long-term care hospitals or rehabilitation facilities after a hospital stay, according to a new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG).

Both types of facilities serve people recovering from serious illness or injury. Long-term care hospitals treat medically complex patients who need hospital-level care for weeks, such as helping them wean off a ventilator or heal difficult wounds. Rehabilitation facilities provide intensive therapy, often after a stroke, hip fracture or spinal cord injury.

OIG investigators reviewed prior authorization decisions, the advance approvals insurers require before they will pay for care, at the 19 largest Medicare Advantage companies in June 2024. Overall, the plans denied 65% of initial requests to enter a long-term care hospital and 54% of requests to enter a rehabilitation facility.

The three biggest insurers stood out. Together, they cover nearly 20 million people, and each denied more than 70% of long-term hospital requests.

• CVS Health Corporation denied 80%.
• Humana Inc. denied 72%.
• United Health Group denied 71%.

All three also turned down more than half of the rehabilitation requests.

• United Health Group denied 66%.
• Humana Inc. denied 54%.
• CVS Health Corporation denied 51%.

When patients challenged a denial, insurers often reversed course.

Plans overturned 36% of long-term hospital denials and 43% of rehabilitation denials on appeal. This may be a sign that some patients were initially refused the care they needed, the report said. Reversal rates varied widely from one company to the next.

For-profit plans also denied requests at higher rates than nonprofit ones, which investigators said suggests financial incentives may play a role.

The report stopped short of calling the denials improper.

Investigators said they could not determine from the data alone how many were inappropriate, but warned that the wide variation between companies raised concern that some patients “may not be receiving services” their plans are required to cover.

Delays can carry real costs. Patients usually wait in a hospital while an appeal on the next level of care is decided, often for five to six days, sometimes longer. Extra days in a hospital acute setting can raise the risk of infections and falls, noted OIG.

The watchdog urged the Centers for Medicare & Medicaid Services to collect more detailed data and examine why denial rates differ so much. The agency neither agreed nor disagreed with the recommendations.

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