Sunday, June 14, 2026

A new HHS OIG report shows Medicare Advantage plans denied prior authorization requests for specialized post-acute care at unusually high rates in 2024 and 2025. The report indicates these denials disproportionately affected requests for skilled nursing, inpatient rehabilitation, and home health services following hospitalizations. This pattern follows earlier OIG findings that MA plans create systematic barriers to medically necessary care. The OIG will likely increase audit scrutiny on MA prior-authorization patterns for these services. Billing teams supporting post-acute transitions should proactively document medical necessity and prepare for a higher volume of appeals on rehab-related claims from MA beneficiaries.

Vendors in the revenue cycle management space are emphasizing AI-driven denial analytics as a core competitive differentiator. Firms like Joyful Health are leaning into predictive modeling to identify claims likely to be denied before submission. The strategic push reflects market pressure to move beyond reactive denial management to pre-emptive prevention. This vendor activity indicates a maturation of AI tools targeting specific, high-cost denial drivers like prior authorization and clinical documentation gaps. For practices evaluating RCM partners, the focus on predictive denial analytics is now a expected feature, not a novelty.

The Senate approved the Patient Access to Stable Treatments (PAST) Act sponsored by Sen. Ron Johnson. The bill prohibits Medicare Part D and Medicare Advantage plans from making mid-year changes to formularies that would drop a covered drug or move it to a higher cost-sharing tier. It also restricts similar actions by Medicaid managed care organizations. The bill now moves to the House for consideration. This is a direct response to patient and provider complaints about non-medical switching and coverage instability mid-plan-year. Monitor the House calendar for scheduling; if enacted, it would set a clear guardrail against payer formulary manipulation.