Wednesday, July 22, 2026

A KFF investigation reveals Deloitte-built Medicaid eligibility and enrollment systems are malfunctioning in at least 25 states, resulting in wrongful denials and terminations of coverage for disabled and low-income beneficiaries. These systemic errors create uninsured patients whose claims will be rejected. The report details how automated systems fail to process documentation correctly, leading to coverage gaps. For practices in affected states, this means a spike in Medicaid eligibility denials unrelated to patient status. Immediately increase front-desk verification for all Medicaid patients and prepare to submit more paper documentation to counter automated system errors. Monitor your state's Medicaid agency for corrective action announcements.

The Health Insurance Prior Authorization Transparency Act has cleared the House Energy and Commerce Committee with bipartisan support and is headed for a floor vote. This bill, championed by Rep. Craig Goldman, requires health plans to publish data on prior authorization approval and denial rates, including statistics on expedited requests and appeals. It targets the lack of public data on payer-specific denial patterns. This reform follows sustained congressional pressure on Medicare Advantage insurers over high denial rates. Track the bill's progress; its passage would force commercial payers to disclose their denial metrics for the first time.

A watchdog analysis reports that the three largest Medicare Advantage insurers, UnitedHealthcare, Aetna, and Humana, collectively deny more than 70% of requests for long-term care services like skilled nursing and home health. This denial rate, detailed in a report covering 2025, underscores the continued pressure on post-acute care authorizations within MA plans. The findings align with ongoing Senate and state-level probes into MA plan denials. For practices managing transitions of care, this reinforces the need for robust clinical documentation and proactive peer-to-peer review processes for post-discharge services under MA contracts. Track the Senate Finance Committee's ongoing inquiry for potential regulatory response.

The House Energy and Commerce Committee advanced a bipartisan bill, led by Rep. Craig Goldman (R-TX), mandating greater transparency in health insurance prior authorization processes. The legislation would require insurers to report denial rates and rationale for PA decisions publicly. This committee vote moves the bill closer to a potential House floor vote, building on momentum from Senate scrutiny of MA denials. While not yet law, the advance signals growing legislative appetite to regulate insurer utilization management. Watch for the bill's progress after the August recess; if enacted, it would create new public data on payer behavior to inform contract negotiations and appeals strategies.

A government watchdog report finds the three largest Medicare Advantage insurers denied more than 70% of requests for long-term care and rehabilitation services. The analysis highlights a systemic pattern where private plans reject expensive, non-acute care, shifting patients back to traditional Medicare or leaving them without coverage. This finding aligns with ongoing Senate Finance Committee investigations into MA denial practices and provides concrete data for billing teams contesting similar denials. Expect increased scrutiny and potential audit activity around skilled nursing facility and inpatient rehab facility authorizations from UHC, Humana, and Aetna MA plans.