A Federal Watchdog Looked at Nursing-Home Denials. When Patients Pushed Back, Insurers Reversed Themselves 95% of the Time.

Picture the moment this report is really about. Someone you love has just come through a hospital stay — a fall, a stroke, a surgery — and is not yet ready to go home. The doctors recommend a short stretch in a skilled nursing facility: a place to recover, to relearn walking, to be watched while the body mends. And the insurance plan says no.

A new report from the Office of Inspector General — the independent watchdog inside the U.S. Department of Health and Human Services — set out to measure how often that "no" happens in Medicare Advantage, and, just as important, how often it holds up when challenged. What it found is worth reading slowly.

What the watchdog found

Looking at nineteen large Medicare Advantage insurers over a single month in 2024, the OIG found that plans denied about 12 percent of requests to admit a patient to a skilled nursing facility. That figure alone hides a lot: individual insurers' denial rates ranged from a fraction of a percent all the way up to 23 percent, depending on which plan you happened to have.

Here is the number that matters most. When patients or their doctors appealed one of those denials, the insurer reversed itself and approved the care 95 percent of the time (Office of Inspector General). Not half the time. Not most of the time. Nearly every time.

A near-total overturn rate is not a sign that the appeals system is working well. It is a sign that the original denials were, in a large share of cases, wrong — that patients who genuinely needed care were told no, and only the ones who fought got it. The OIG says as much: the extremely high overturn rate, in its words, raises concerns that some enrollees were initially denied medically necessary care, and it points to the far larger group who never appealed at all.

Two more findings sharpen the picture. One contractor, naviHealth — a company that handles prior-authorization decisions for insurers and, the report notes, is a subsidiary of UnitedHealth Group — processed half of all the nursing-facility requests reviewed. It denied them at a higher rate than the plans that decided in-house, and when its denials were appealed, 97 percent were overturned. And requests coming from people who already lived in a nursing home were denied 40 percent of the time — nearly four times the rate for everyone else.

The context worth understanding

In my years in specialty pharmacy, I learned that an overturn rate is a kind of confession. When an insurer approves a claim it had denied, as soon as a human being looks again, it is telling you the first answer did not deserve the weight it was given. One reversal is an honest mistake. A 95 percent reversal rate, across nineteen companies, is a pattern — and patterns are chosen, not accidental.

The reason patterns like this persist is not mysterious, and it is the quiet engine underneath almost every denial story. The system runs on the expectation that most people will not push back. In this data, only 18 percent of nursing-facility denials were appealed at all. That means for every patient who challenged the "no" and won, several others simply accepted it — went home before they were ready, paid out of pocket, or went without. The denial did its work not because it was correct, but because it was rarely questioned.

What it means for you

If you or someone you care for is on a Medicare Advantage plan and is denied coverage for short-term nursing care after a hospital stay, this report is, in an odd way, encouraging news. It tells you, in the government's own numbers, that these particular denials are overturned almost every time they are appealed. The "no" you received is far more fragile than it looks.

It also means something broader about how to read any denial. A refusal that arrives before you have appealed is a first position, not a final ruling — and the data here shows just how often that first position collapses under a second look.

What you can do today

Do not accept a post-hospital nursing-care denial as final. In this class of care, appeals succeed at extraordinarily high rates. Silence is the only outcome the system counts on.

Ask, in writing, for the specific reason your request was denied and the clinical criteria the plan used. You are entitled to both.

Get your doctor's recommendation for the skilled nursing stay documented and submitted with your appeal. The treating clinician's judgment is your strongest evidence.

Note your deadlines and appeal promptly. Medicare Advantage appeals run on clocks; mark the date of the denial and ask how long you have.

Ellen can help you read a denial, find the coverage rule behind it, and build the appeal — including for post-hospital nursing care, where the odds of reversal are, by the government's own accounting, remarkably high. The first "no" is often the weakest part of the whole process. It is counting on you not to ask again.

Ellen does not provide medical advice. For treatment decisions, talk to your doctor.

Source: U.S. Department of Health and Human Services, Office of Inspector General, "Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission" (2026; OEI-09-24-00330). 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/