Medicare Advantage Denials: 95% of SNF Appeals Overturned

On June 8, 2026, the HHS Office of Inspector General released two reports on prior authorization denials in Medicare Advantage. One looked at requests for skilled nursing facility (SNF) admission. The 19 Medicare Advantage organizations in the review denied 12 percent of those requests. When a denial was appealed, the plan reversed it 95 percent of the time. Only 18 percent of denials were ever appealed (OIG, 2026).

Put those numbers side by side. Nearly every denial that got a second look was reversed, and more than four out of five never got one.

The OIG treats this as a problem with how plans make initial decisions. Revenue cycle teams should also read it as a follow-up problem. Whether a wrongful denial gets reversed or written off often depends on whether anyone pursued it.

What the OIG Found

The SNF report (OEI-09-24-00331) covers requests from June 2024. Three findings stand out.

• Denial rates varied widely by plan, from 23 percent at the high end to 0.4 percent at the low end.
• One contractor, naviHealth, handled half of all SNF requests. It denied 14 percent of the requests it reviewed, and plans later reversed 97 percent of the naviHealth denials that were appealed.
• Nursing home residents were denied far more often: 40 percent of the time, compared with 11 percent for other enrollees.

The companion report (OEI-09-24-00330) looked at long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs). The three largest Medicare Advantage organizations denied these requests at higher rates than most of their peers. When enrollees appealed, plans reversed 36 percent of LTCH denials and 43 percent of IRF denials. For IRFs, the reversal rate ranged from 14 percent to 86 percent depending on the plan. The OIG found that "high denial rates were driven by contractors that denied prior authorization requests on behalf of the MAOs" (OIG, 2026).

The Pattern Holds Beyond Skilled Nursing

KFF's analysis of 2024 Medicare Advantage data shows the same pattern across all services. Plans received nearly 53 million prior authorization requests and denied 4.1 million of them, or 7.7 percent. Just 11.5 percent of those denials were appealed. Of the ones that were, 80.7 percent were overturned in full or in part (KFF, 2026).

Reversal rates varied by insurer, from 51.0 percent at Kaiser Foundation Health Plan to 95.5 percent at Centene. That spread matters when you decide which denials to work first.

Why So Few Denials Get Appealed

For many revenue cycle teams, limited follow-up capacity is likely one reason denials go unappealed.

An appeal starts with information the team often doesn't have yet: the exact denial reason, what documentation the plan wants, the deadline, and whether a peer-to-peer review is available. Getting it usually means a portal lookup, a phone call, or both. After that, someone has to track the appeal until it resolves.

That work competes with everything else on the same desk. The AMA's 2026 physician survey found prior authorization takes an average of 13 hours of physician and staff time per week. Forty percent of practices employ staff who work only on prior authorization, and 74 percent of physicians say denials have increased over the past five years (AMA, 2026). With a queue that deep, lower-dollar and harder-to-reach denials age past their deadlines.

One recent change helps. Since January 1, 2026, payers covered by the CMS Interoperability and Prior Authorization Final Rule, including Medicare Advantage plans, must give a specific reason for every denied prior authorization (CMS, 2024). A specific reason makes triage faster, as long as someone captures it and acts on it.

The Math for a Revenue Cycle Team

The numbers in this example are hypothetical. They show the shape of the problem.

Say a provider group receives 400 prior authorization denials from Medicare Advantage plans in a quarter. At an 11.5 percent appeal rate, about 46 get appealed. At an 80 percent reversal rate, about 37 are overturned.

Now the team raises its appeal rate to 40 percent, or 160 appeals. Even if the reversal rate falls to 60 percent because the team is appealing weaker cases, that is 96 reversals, about two and a half times as many as before. In this example, the only variable that changed is follow-up capacity.

Your numbers will differ by payer mix, service line, and denial type, so measure your actual rates before building a business case.

What Systematic Denial Follow-Up Looks Like

1. Capture the denial reason the same day

Record the specific reason, the reference number, the appeal deadline, and the documentation the plan needs. Store them as fields rather than in free-text notes.

2. Triage by likelihood of reversal

Track reversal rates in your own history by payer, service, and denial reason, and work the denials most likely to be reversed first. The OIG findings suggest contractor-issued denials deserve a close look.

3. Put every open appeal on a clock

Check status at set intervals instead of waiting for correspondence. From the outside, an appeal stuck in a queue looks the same as one that is moving.

4. Track appeal rate as a KPI

Most teams track denial rate and overturn rate. Few track the share of denials they actually appeal, which is the number that shows how much recoverable revenue is going unworked.

5. Keep an audit trail

When you escalate, reopen, or dispute a denial, you need timestamps, call reference numbers, and a record of what the payer told you.

Where Automation Fits

Much of this work is repetitive retrieval: calling a payer to confirm a denial reason, checking appeal status, confirming what documentation is missing. Automation handles that part well, which leaves your team more time for writing appeals and preparing for peer-to-peer reviews.

SuperDial's voice AI agents call payers to retrieve denial reasons, claim status, and appeal status. Each call comes back as structured fields with a recording, a transcript, and a full audit trail. When the phone isn't the fastest route, SuperDial checks EDI, APIs, and payer portals first. The point is to make it affordable to follow up on every denial, including the ones your team would otherwise never get to.

Sources

1. HHS Office of Inspector General. "Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials" (OEI-09-24-00331). June 8, 2026. https://oig.hhs.gov/reports/all/2026/medicare-advantage-organizations-overturned-nearly-all-appealed-prior-authorization-denials-for-skilled-nursing-facility-admission-raising-concerns-about-initial-denials/
2. HHS Office of Inspector General. "The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates" (OEI-09-24-00330). June 8, 2026. https://oig.hhs.gov/reports/all/2026/the-three-largest-medicare-advantage-organizations-denied-requests-for-long-term-acute-care-and-inpatient-rehabilitation-at-some-of-the-highest-rates/
3. KFF. "Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024." January 28, 2026. https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/
4. American Medical Association. "AMA survey: Prior authorization reform pledge falls short for physicians." May 13, 2026. https://www.ama-assn.org/press-center/ama-press-releases/ama-survey-prior-authorization-reform-pledge-falls-short-physicians
5. CMS. "CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)" fact sheet. January 17, 2024. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

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