What the Headlines Missed: Medicare Advantage Plans Denied 161,000 Skilled Nursing Facility Stays In A Year
The New York Times and Washington Post covered the government’s report. Here’s what those stories didn’t explain.
The New York Times and Washington Post both covered a major federal watchdog report released this week on Medicare Advantage prior authorization denials for skilled nursing facility care. It’s short-term medical care and rehabilitation after a hospital stay that provides 24-hour nursing, daily physical and occupational therapy, medical supervision — as a bridge between the hospital and home.
The bombshell finding in the OIG report — and the number focused on — is that while Medicare Advantage plans denied only 12% of SNF admission requests, 95% of patients who appealed those denials won. And, the OIG didn’t mince words:
“The extremely high overturn rate of appealed SNF admission denials raises concerns that more initial SNF requests should have been approved rather than denied because the MAO ultimately determined the requested care was medically necessary.”
And both stories focused on the monthly numbers the OIG published — because the OIG analysis covered only one month: June 2024.
Here’s what nobody calculated: what those numbers look like over a full year. And what they mean if it’s your parent in that hospital bed.
Let’s Make This Real
Your mom just had a hip fracture. Or your dad had a stroke. After four days in the hospital they are medically stable but weak — and the medical team recommends a skilled nursing facility stay because they can’t independently and safely get dressed, make a meal, take a bath, or use the bathroom.
Their Medicare Advantage plan says no. They approve home health care instead — a nurse, a physical therapist, and an aide for an hour or two, a few times a week.
Who fills in the rest of the time? You do. An untrained family caregiver, overnight, without a choice.
The Numbers Nobody Annualized
The OIG study covered one month — June 2024. If you multiply by 12 to capture the impact over a whole year:
The 19 largest Medicare Advantage plans issued approximately 161,000 SNF denials
Only 18% of patients appealed — and 95% of those appeals were overturned
Roughly 132,000 patients were denied and didn’t appeal
Applying that same 95% overturn rate, approximately 125,000 of them would likely have been approved
Those 125,000 patients, and the family members who stepped in to fill the gap, were in all likelihood entitled to that skilled nursing facility stay.
What the Plan Saved — And What It Cost Families
A SNF stay costs Medicare an average of $16,000. Home health care costs $6,000. Every time a SNF denial sticks, the plan saves about $10,000.
Annualized, the three largest plans saved $1.05 billion from denials that are likely to have been wrong. And the total across 19 plans was $1.25 billion.
And that $1.25 billion went to the bottom line of the insurers — instead of to the unpaid family caregivers who had no warning, no training, and no real choice.
What You Can Do Right Now
1. If you’re denied a SNF admission — appeal. Immediately. The data says you will very likely win. A decision typically comes within 5–6 days. Accepting a denial that is almost certainly wrong is the only guaranteed losing move.
2. Get the hospital team’s recommendation in writing before you leave. Your physician’s documented clinical judgment is your most powerful tool in an appeal.
3. If you are enrolling in Medicare for the first time, consider choosing Traditional Medicare rather than a Medicare Advantage plan. And, if you are already on Medicare, consider switching this fall when Medicare open enrollment opens (October 15–December 7), reconsider. I know it’s more expensive, but traditional Medicare does not require prior authorization for SNF admissions. Your doctor’s recommendation is enough and it removes the insurance company from the decision at one of the most vulnerable moments of a patient’s life.
The Bottom Line
The OIG published its findings. CMS responded without agreeing or disagreeing with any of the recommendations. How long the investigation and any enforcement takes is an open question.
In the meantime: the monthly numbers in the headlines were accurate. They just weren’t the whole story.
Data source: HHS Office of Inspector General, OEI-09-24-00331, June 2026. Savings estimates apply reported per-plan SNF overturn rates to unappealed denials × 12 months, using the OIG-cited cost differential of $10,000 per admission (SNF avg. $16,000 vs. home health avg. $6,000, per MedPAC 2025).