In June 2026, the U.S. Department of Health and Human Services Office of Inspector General released a report examining how Medicare Advantage plans handle prior authorization requests for skilled nursing facility admissions. OIG found that plans denied 12.3% of SNF admission requests. Enrollees and providers appealed only 18% of those denials, but when they appealed, plans overturned 94.6% in favor of the enrollee.
News outlets and advocacy groups focused on what these numbers say about Medicare Advantage oversight and access to care. The operational issue received far less attention: Why are so few Medicare Advantage SNF denials being appealed when nearly all of the appeals reviewed by OIG resulted in an approval?
For SNFs, the gap between the 18% appeal rate and the 95% overturn rate is not simply an advocacy statistic. It points to a patient-access and revenue cycle problem operators can address.
OIG reviewed June 2024 data from the 19 largest Medicare Advantage parent organizations, representing 86% of MA enrollment. The plans received 109,387 SNF admission requests and denied 13,458. Denial rates ranged from 0.4% to 23.4%.
Why should SNFs appeal Medicare Advantage denials?
HHS OIG found that Medicare Advantage plans denied 12.3% of SNF admission requests reviewed in its study. Only 18% of those denials were appealed, but plans overturned 94.6% of appealed denials. For SNFs, that gap highlights an opportunity to strengthen denial management, protect patient access and recover revenue when an appeal is clinically supported.
Important context: OIG studied SNF admission prior authorization requests, not every type of Medicare Advantage claim denial. The 94.6% overturn rate applies only to denials that were appealed. It does not mean that 94.6% of every unappealed denial would have been overturned.
Medicare Advantage SNF denial rates by plan
The three organizations with the largest request volumes, UnitedHealth Group, Humana and CVS Health, also had some of the higher denial rates. Molina had the highest denial rate in the study. OIG did not conclude that any single denial rate was automatically right or wrong, but it questioned the wide variation among organizations.
| MAO parent organization | SNF denial rate | Appeal overturn rate |
|---|---|---|
| Molina Healthcare | 23.4% | Not reported |
| Kaiser Foundation | 14.0% | Not reported |
| Humana | 13.5% | 92.1% |
| CVS Health (Aetna) | 13.5% | 98.2% |
| UnitedHealth Group | 12.9% | 99.7% |
| All 19 MAOs | 12.3% | 94.6% |
Source: HHS OIG, OEI-09-24-00331, Appendix B. OIG reported overturn rates only for organizations with at least 50 SNF appeals. See the full report for results from all 19 organizations.
Contractors also matter. NaviHealth processed half of all SNF requests, denied 14.3% and had 96.6% of its appealed denials overturned by the plans. SNFs should track the plan, product, reviewing contractor, denial reason and appeal result separately. Grouping everything under one payer name can hide where the process is breaking down.
OIG also found that long-stay nursing home residents were denied SNF-level care 39.5% of the time, compared with 11.5% for other enrollees. Place of residence does not eliminate the need to evaluate whether a resident meets Medicare’s requirements for daily skilled care.
Delay is also part of the cost. Enrollees who appealed typically waited six days from the initial request to the appeal decision, and 17% waited 10 days or longer. When the plan approved the initial request, it typically did so the same day. For residents waiting in a hospital, those extra days can delay rehabilitation, complicate discharge planning and create additional stress for residents and their families.
Why Medicare Advantage SNF denials aren’t being appealed
Most facilities do not deliberately ignore strong appeals. Instead, denials can get lost between departments, competing priorities and organizations.
Common breakdowns include:
- The hospital submitted the authorization, so the SNF assumes the hospital owns the appeal.
- The denial notice never reaches the SNF team reviewing referrals.
- Nobody verifies who has authority to act for the enrollee.
- The clinical record does not clearly connect the resident’s condition to the need for daily skilled care.
- Staff do not know whether to request expedited or standard reconsideration.
- The facility tracks admitted residents and claims but not denied referrals that never became admissions.
The tracking gap may be the most expensive. If the denial log starts only after admission or claim submission, a missed admission never reaches the aging report. The potential revenue loss remains largely invisible.
A practical Medicare Advantage SNF appeals process
Every denial should be logged and reviewed. Every clinically supportable denial with a valid basis for reconsideration should move through a consistent process.
1. Capture the denial. Obtain the written notice and record the plan, contractor, denial reason, notice date, deadline and appeal instructions.
2. Confirm the right party and urgency. An enrollee, representative or physician may request reconsideration. If a delay could harm the resident’s health or recovery, have the physician request an expedited review when appropriate.
3. Build the clinical case. Address the stated denial reason directly and explain why a lower level of care cannot safely meet the resident’s daily skilled needs.
4. File and confirm receipt. Retain the portal confirmation, fax record or delivery receipt and assign a specific follow-up date.
5. Track the result. Record the decision and revenue outcome. If the plan upholds the denial, confirm whether the case proceeds to automatic review by the Part C Independent Review Entity.
CMS timeframes: File reconsideration within 65 calendar days of the organization determination notice. Expedited pre-service reconsiderations must be decided within 72 hours, while standard pre-service reconsiderations generally allow up to 30 calendar days. Always follow the actual denial notice and plan instructions.
Build the SNF appeal around the denial reason
A generic letter stating that the resident needs skilled care is not enough. The appeal should directly address why the plan denied the request.
If the plan says the resident can receive care at a lower level, explain why home health, outpatient therapy or custodial nursing facility care cannot safely meet the resident’s needs. Connect the physician’s recommendation, diagnoses, nursing needs, therapy evaluations, prior level of function, current functional loss, cognitive or safety barriers and discharge risks to the need for daily skilled care.
If information was missing from the original request, fix the gap. CMS noted in its response to OIG that an initial denial may have been warranted when documentation supporting coverage was not provided until the appeal. That makes a complete initial authorization request just as important as the appeal itself.
The goal is not simply to appeal more denials. It is to identify clinically supportable cases quickly, submit the right evidence and build a repeatable process that prevents viable cases from disappearing between teams.
What not appealing Medicare Advantage SNF denials can cost
Do not apply OIG’s 95% overturn rate to every unappealed denial. Instead, use your facility’s own results to calculate the potential improvement from appealing more clinically supportable cases.
Incremental revenue opportunity = eligible denials × increase in appeal rate × facility overturn rate × expected net revenue per authorized stay.
For example, a facility has 20 clinically supportable denials, raises its appeal rate from 18% to 60%, has a 75% overturn rate and expects $12,000 in net revenue per stay.
The opportunity is:
20 × 42% × 75% × $12,000 = $75,600
That represents $75,600 in potential incremental revenue before appeal labor and related costs. Facilities should use net contracted reimbursement, actual capacity and their own historical overturn rates when calculating the opportunity.
Track SNF denial management as a KPI
Review Medicare Advantage denial and appeal results monthly by plan, product and contractor. At minimum, track:
- Denial rate
- Appeal rate
- Overturn rate
- Days from denial to submission
- Days from submission to decision
- Denial reason
- Net revenue recovered
A high overturn rate combined with a low appeal rate can indicate that the process works when teams use it but that too many potentially viable cases never reach the appeal stage.
Assign one accountable owner to move every case, but do not expect one person to create the clinical argument alone. Admissions should capture the referral and notice. Nursing and therapy should explain the skilled need. The physician should support urgency and medical necessity when appropriate. The business office should track deadlines, reimbursement and outcomes.
Use the dashboard to change behavior, not simply report numbers. A plan with a high denial rate and high overturn rate should trigger a review of documentation, submission practices and the plan’s decision patterns. A low overturn rate may point to weak case selection or documentation gaps. Both results require a response, but they do not require the same response.
SNF denial management: What to change now
Start by pulling the last 90 days of Medicare Advantage SNF admission denials, including referrals that never became admissions. Separate coverage denials from incomplete requests, network issues and administrative outcomes so your team understands what is actually driving lost admissions.
Then strengthen the process:
- Name one accountable owner and establish a same-day escalation process.
- Build a denial-specific clinical checklist and standard appeal cover sheet.
- Track denied referrals even when the resident never enters the facility.
- Review appeal and overturn rates monthly by plan, product and contractor.
- Measure the net revenue recovered through successful appeals.
- Use recurring denial patterns to improve initial authorization submissions.
The OIG report should not sit in a policy file. For SNF operators, the findings point to a measurable revenue cycle opportunity: identify clinically supportable denials, appeal them consistently and use the results to strengthen the authorization process upstream.
A Medicare Advantage denial may be the plan’s first answer. It should not automatically become the facility’s final answer.
Sources: HHS Office of Inspector General, Medicare Advantage Organizations Denied Prior Authorization Requests for Skilled Nursing Facility Care at Widely Varying Rates (OEI-09-24-00331); Centers for Medicare & Medicaid Services, Medicare Advantage reconsideration guidance.
