CHA News

Office of Inspector General to Examine Medicare Advantage Use of Prior Authorization for Post-Acute Care

What’s happening: The U.S. Health and Human Services Agency has announced that the Office of Inspector General (OIG) will investigate the use of prior authorization for post-acute care services by Medicare Advantage (MA) plans.   

What else to know: CHA members have reported that they encounter significant challenges in obtaining authorizations from MA plans for access to the most appropriate level of post-acute care (PAC).  

Though MA plans are required to cover at least the services as original Medicare, prior review by the OIG revealed that MA plans sometimes denied prior authorization requests for post-acute care even though the requests met Medicare coverage rules. OIG’s investigation will examine selected MA plans’ processes for reviewing prior authorization requests for post-acute care in long-term acute care hospitals, inpatient rehabilitation facilities, and skilled-nursing facilities.   

The OIG will also review the extent to which the selected MA organizations denied requests for post-acute care and examine the care settings to which patients were discharged from the hospital. The anticipated release date for the report is in 2026.