A federal audit has revealed that major Medicare Advantage insurers improperly denied claims at alarming rates — leaving millions of seniors without care they were entitled to receive.
Audit Findings
- 13% of prior authorization denials were improper (should have been approved)
- 18% of payment denials overturned on appeal — but only 1% of patients appealed
- AI-powered denial systems rejected claims in as little as 1.2 seconds
- Some insurers denied 25%+ of all claims automatically
Worst Offenders
UnitedHealthcare, Humana, and CVS/Aetna had the highest improper denial rates. All three face potential fines and are required to implement corrective action plans.
What Seniors Should Do
Always appeal denials. The success rate on first appeal is 75% — most seniors don't realize they can challenge decisions. Call 1-800-MEDICARE for free help. Your state's Health Insurance Assistance Program (SHIP) provides free counseling.
CMS has proposed new rules requiring Medicare Advantage plans to approve care within 24 hours for urgent requests and 7 days for standard ones, with penalties for excessive denials.
