If findings on Medicare Advantage plans are true, CEO heads must roll

Tom Slade

Submitted photo/Tom Slade

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OPINION — It has come to my attention that some of the largest Medicare Advantage plans have been identified by Health and Human Services and Office of Inspector General as having engaged in questionable denials of some Medicare benefits.

This information was disclosed in HHS OIG report dated June 8, 2026, (OEI-09-24-00330).

Under a Medicare Advantage plan, Medicare Part B dollars are managed by a for-profit insurance company that determines necessary care. According to the OIG report, decision-making for certain types of covered care may not coincide with Medicare rules which Medicare Advantage is required to follow.

On appeal, initial denials were frequently determined to meet Medicare coverage and billing rules and were overturned in favor of the Medicare enrollee.

Frequent denials include:

• Inpatient rehabilitation facilities and long-term acute-care hospitals — the three largest Medicare Advantage organizations denied prior authorization requests for inpatient rehabilitation facilities admission more often than most peers. Many of these initial denials were overturned on appeal, according to the June report.

• Skilled nursing facilities — Medicare enrollees and providers appealed 18% of skilled nursing facilities denials. When appealed, the denials were overturned 95% of the time, according to the report. The OIG report concluded that the extremely high overturn rate indicates that some enrollees were initially denied medically necessary care and “raises concerns about denials that were not appealed.”

Information disclosed in this report is appalling and represents nothing less than elder abuse, in my opinion. To deny necessary Medicare Advantage coverage that should have been approved as submitted for any reason is unacceptable.

This should be immediately investigated by Congress.  If Medicare Advantage companies are found guilty of purposefully and wrongly denying Medicare benefits due to any failing of the Medicare Advantage company, there should be substantial fines collected and jail time for CEOs.

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