Prior Authorization: What OIG’s Medicare Advantage Data Really Shows

The findings raise questions about both plan review practices and provider documentation quality — and point toward solutions.

Last week’s HHS Office of Inspector General reports on Medicare Advantage prior authorization denials dominated the headlines — in the Wall Street Journal, the New York Times, and across the trade press. The coverage focused, understandably, on the numbers: 65% of long-term acute care hospital (LTCH) requests denied. 54% of inpatient rehab facility (IRF) requests denied. A 95% appeal overturn rate for skilled nursing facility (SNF) denials. A plan reversing its own decisions at rates approaching 100%. 

Those numbers matter. But buried inside the OIG Medicare Advantage report — and largely missing from the national coverage — is a finding that deserves equal attention, and that points toward a more constructive path forward. Namely, the prior authorization process has problems on multiple sides of the transaction, and some of those problems are addressable. 

The OIG data raises two distinct and equally important questions. First, are health plans making initial determinations that are appropriate and consistent with Medicare coverage criteria? And second, is the documentation provided at the time of initial review sufficient to support approval? The answer to both questions matters — and the OIG’s findings suggest that neither side of the transaction is working as well as it should. 

For government healthcare agencies and program administrators, these questions are serious. Inconsistent medical necessity determinations, high appeal volumes, and documentation gaps each carry consequences including compromised beneficiary/patient access to appropriate care, weakened payment integrity, administrative burden absorbed across the system, and reduced defensibility when programs face audit or oversight scrutiny. 

What the OIG Data Shows 

The scale is vast. The two OIG reports released June 8, 2026 — OEI-09-24-00331 (SNFs) and OEI-09-24-00330 (LTCHs and IRFs) — reviewed prior authorization data from June 2024 for the 19 largest Medicare Advantage plans, covering 29.3 million enrollees at the time. 

The headline findings across post-acute care settings: 

• SNFs: 12% of admission requests denied; 95% of appealed denials overturned. One large health plan received 42% of all SNF appeals and overturned 99.7% of them. 

• IRFs: 54% of admission requests denied overall; individual plan rates ranged from 4% to 66%. Appeal overturn rates at some plans exceeded 80%. 

• LTCHs: 65% of admission requests denied overall; the three largest plans had the highest rates. 

What the Numbers Don’t Resolve  

The OIG data alone cannot resolve how much of the appeal overturn rate reflects plans reversing decisions that should never have been denied, versus plans approving claims when more complete documentation was provided. Both dynamics are likely at work. Both deserve attention. 

What is clear is that inconsistency — both in how plans apply coverage criteria and in the completeness of provider-submitted documentation— is a systemic opportunity for improvement.   

What This Means for the Reform Conversation 

The prior authorization reform movement — driven by legislative pressure, voluntary insurer commitments, and CMS rulemaking — is focused primarily on reducing the volume of services requiring authorization. As we analyzed recently, this reform is real, but it won’t eliminate payment integrity scrutiny, which likely will simply shift from front-end authorization to back-end audit. Regardless of how payment integrity reviews may shift, the processes always will rely on demonstrated alignment with coverage policy.   

The OIG’s findings add urgency to the prior authorization conversation, and the need to consider not just whether fewer services should require authorization, but whether the PA process — when it applies — is working fairly and efficiently for patients, providers, and plans alike. That conversation needs to address both the consistency and appropriateness of initial plan determinations and the quality of clinical documentation that enters the review process. 

Getting this right is not only a matter of administrative efficiency and program integrity – it’s a matter of patient care. A prior authorization process that functions well — with objective, evidence-based determinations and documentation that supports them from the start — serves all these interests simultaneously. 

How FHAS Can Help 

As an independent, neutral partner with no financial stake in authorization outcomes, FHAS is a URAC-accredited IRO with Health Utilization Management (HUM) accreditation, which verifies that we bring objective clinical and operational expertise to the review process — supporting evidence-based determinations, improving consistency, and producing decisions that hold up under audit and appeals scrutiny for both government- and employer-sponsored health plans. We also support post-acute care providers and hospitals working to strengthen initial prior authorization documentation across SNF, IRF, and LTCH settings.  

As policymakers continue to evaluate prior authorization reform, organizations will increasingly need partners that can balance beneficiary access, clinical quality, operational efficiency, and program integrity. FHAS brings nearly three decades of experience supporting that mission.