GAO Report Highlights Prior Authorization Delays in Medicare Advantage SNF Coverage

A Government Accountability Office report released this week found that Medicare Advantage plans deny or delay skilled nursing facility admissions at significantly higher rates than traditional Medicare, recommending that CMS strengthen oversight of prior authorization practices. The report examined SNF utilization patterns across MA plans and identified concerning variations that may affect beneficiary access to post-acute care.

Key Findings

The GAO analysis found that MA beneficiaries use SNF services at rates 15-20% below traditional Medicare beneficiaries with similar health profiles, suggesting that plan utilization management practices may be limiting access. Prior authorization denial rates for SNF admissions averaged 8.4% across MA plans examined, compared to essentially zero denials under traditional Medicare’s coverage determination process.

Additionally, the report found that average SNF length of stay for MA beneficiaries was 4.2 days shorter than for traditional Medicare beneficiaries, potentially indicating premature discharge pressure from concurrent review processes.

Plan Responses

America’s Health Insurance Plans (AHIP), representing MA insurers, disputed the GAO’s conclusions, arguing that lower SNF utilization reflects MA plans’ success in providing appropriate care in less restrictive settings. AHIP noted that MA plans offer benefits like home health care and telehealth that may reduce the need for institutional post-acute care.

The trade group also pointed to the SNF 3-Day Rule Waiver available to many MA plans, which allows SNF admission without a qualifying hospital stay, as evidence that plans support appropriate SNF access.

Recommendations

The GAO recommended that CMS: require MA plans to report prior authorization denial rates and appeal outcomes for SNF services; establish minimum standards for SNF prior authorization timeframes; and conduct targeted audits of plans with high denial rates or short average lengths of stay. CMS concurred with all recommendations and indicated it would address them in future rulemaking.