Two reports from U.S. investigators have highlighted issues with Medicare Advantage plans and how they reject requests for short-term nursing home or inpatient rehab services.

The reports revealed that major insurers, who are responsible for selling Medicare Advantage plans, denied approximately 13% of patients’ requests to recover in a skilled nursing facility following surgery or serious illness. These plans cover about 35 million older Americans under the federal Medicare program.

Private Medicare Advantage plans have faced criticism for their approach to managing healthcare, often denying medically necessary care. These plans require prior authorization before agreeing to cover treatments. The financial structure allows insurers to save money by minimizing expenses, which can lead to denying admissions to expensive inpatient facilities. Patients may be diverted to outpatient services or sent home instead of receiving specialized rehabilitation or therapy.

The inspector general’s office at the Department of Health and Human Services produced two reports focusing on UnitedHealth Group, Humana, and CVS Health. These companies represent the majority of people enrolled in Medicare Advantage plans. A key concern is whether the contractors used to determine care needs are adequately supervised. The influence of few large insurers and their contractors means that their policies greatly affect millions of Americans.

Rosemary Bartholomew, leading the government team, emphasized that the market dominance of these large insurance companies and their use of contractors can significantly impact care for countless individuals.