KFF's analysis of the first payer-level prior authorization data CMS required insurers to publish shows standard requests were denied 12% of the time in Medicare Advantage, 14% in Medicaid managed care, and 18% in the ACA marketplaces in 2025 — with individual insurers ranging from 2% to 25%. McKnight's flagged the finding that matters most for nursing homes this morning: Medicaid managed care, the payer family that covers the majority of long-stay residents in managed-care states, says no more often than Medicare Advantage and overturns fewer denials on appeal. Separately, Minnesota won federal approval to put $36 million in Medicaid money behind a nursing home worker wage floor that takes effect next month — in what Rehinged scoring shows is already the best-staffed sizable state market in the country.
Why it matters for vendors: Payment friction just became measurable, attributable, and public — every operator can now see which of their payers is the outlier, and every vendor selling denials management, prior-auth automation, or documentation tooling can open with a number the buyer can verify. The other side of the ledger is who can afford the friction: the 340 facilities Rehinged scores at high penalty risk run 73.6% occupancy against an 80.9% national average and 1.26 stars, and 195 of them churn more than half their nursing staff a year. Buildings with no census cushion and no administrative bench are the ones an unappealed denial actually hurts — and two-thirds of appealed Medicare Advantage denials get overturned.
Reimbursement
Market Trends
Medicaid managed care denies prior authorizations more often than Medicare Advantage — and for the first time, the rates carry insurer names
What happened
KFF published the first analysis of prior authorization data that CMS compelled insurers to release, covering roughly 71 million enrollees across three markets in 2025. Standard requests were denied 12% of the time in Medicare Advantage, 14% in Medicaid managed care, and 18% in the ACA marketplaces; expedited requests fared only slightly better at 10%, 12%, and 16%. The variation among named insurers is the striking part: standard-request denial rates ran from 5% at Elevance to 17% at UnitedHealth Group within Medicare Advantage, and from 2% at L.A. Care Health Plan to 23% at Independence Health Group within Medicaid managed care.
Appeals tell the second half of the story. When denials were appealed, 67% were overturned in Medicare Advantage, against 47% in Medicaid managed care and 43% in the marketplaces. McKnight's coverage this morning drew the long-term care conclusion: the payer family that covers most long-stay nursing home residents in managed-care states denies more and reverses less.
Why it matters
Two payer relationships govern SNF revenue, and this data quantifies the friction in both. Medicare Advantage controls short-stay admissions and continued-stay approvals — the referrals a building lives on. Medicaid managed care increasingly runs the long-stay book as states move custodial populations into managed plans. A 14% standard denial rate on the majority payer, with less than half of appealed denials reversed, is a structural collections problem, not an occasional annoyance.
For vendors, the overturn rates are the sales math. Two-thirds of appealed Medicare Advantage denials get reversed, which means facilities without the administrative capacity to appeal are leaving recoverable revenue on the table at a knowable rate. Denials management, prior-auth automation, clinical documentation, and revenue-cycle vendors can now anchor the pitch to published, insurer-specific numbers the CFO can check — and the buildings can benchmark their own payer mix against named plans for the first time.
Payment friction lands hardest where there is no slack to absorb it. Rehinged scores penalty and payment-pressure exposure across the 6,576 facilities with sufficient enforcement and payment data, and 340 facilities score 70 or higher — the threshold where the signal is strong enough to act on. That cohort averages 1.26 overall stars, runs 143 beds, and fills just 73.6% of them against an 80.9% national average. These are the buildings where a denied continued-stay authorization is not an accounting entry — it is an empty bed the census cannot cover.
340
facilities at high penalty risk
73.6%
occupancy vs. 80.9% national
195
also churn >50% of nursing staff
Facilities at high penalty risk, by state
Crossing penalty risk against workforce churn isolates the pool with the least capacity to fight back: 195 of the 340 high-penalty-risk facilities also turn over more than half their nursing staff a year — 65% on average — and that group holds just 1.15 stars. A building replacing two-thirds of its nurses annually does not have a business office running payer appeals, which is exactly why 67% overturn rates go unclaimed. The opposite end of the market matters too: the 1,924 facilities Rehinged scores high on value-based incentive exposure are larger, better-rated buildings with real Medicare Advantage census and revenue worth defending. Denials-management and prior-auth automation vendors should work both lists differently — the distressed pool as an outsourced-appeals pitch, led by Illinois with 130 high-penalty-risk buildings, and the VBP-exposed pool as a revenue-integrity pitch where the buyer already knows what a percentage point of Part A collections is worth.
Watch for: The CMS Interoperability and Prior Authorization rule's remaining deadlines — impacted Medicare Advantage and Medicaid managed care plans face electronic prior-auth API requirements by January 2027, layered on the shortened decision windows that took effect this year. Also watch whether next year's disclosure adds service-level detail; a post-acute-specific denial rate would turn this from a market signal into a named-account targeting tool.
Staffing
Reimbursement
Washington approves Medicaid dollars for Minnesota's nursing home wage floor — in the best-staffed sizable state market in the country
What happened
After more than eight months of delays, the federal government approved Minnesota's plan to put Medicaid money toward a minimum wage for nursing home workers. Under the agreement, $36 million in Medicaid dollars — half federal, half state — will fund the wage floor, which takes effect next month. The approval ends a long stretch of uncertainty for operators who had been planning payroll around a mandate with no confirmed funding source behind it.
Why it matters
A publicly funded wage floor permanently raises the labor-cost baseline of every building in the state — but it also changes what operators buy. When wages are set by policy and funded by Medicaid, the competitive variable shifts from pay rates to everything around them: scheduling, retention, credentialing speed, and how much of the labor budget leaks to overtime and agency premiums. Minnesota just became a market where workforce-efficiency tooling competes on operations, not on wage arbitrage — and where other states with workforce standards boards will be watching whether the federal match model travels.
The wage floor is arriving in a market that already staffs like no other. Minnesota's 338 scored facilities report 1.06 RN hours per resident day against a 0.69 national average — the highest of any state with more than 100 facilities — and hold an average staffing rating of 4.17 stars against 2.91 nationally. Nursing turnover runs 42.3% against 45.9%, and Rehinged's staffing-need score for the state averages 14.0 against 26.3 nationwide. Minnesota buildings are also small, averaging 71 beds, which makes every departing nurse proportionally more expensive to replace.
1.06
MN RN hours per resident day
4.17
avg staffing stars vs. 2.91 national
78
MN facilities churning >50% of staff
Reported RN staffing, hours per resident per day
The commercial story lives in Minnesota's tail. The 23 facilities holding a staffing rating of two stars or fewer report just 0.56 RN hours per resident day — below the national average — and churn 56.6% of their nursing staff, in a state where 90 buildings hold five overall stars and the median competitor staffs at four. Once the wage floor equalizes pay, those bottom-tier buildings lose their last excuse and their last lever: they will be bidding the same dollars as the five-star building across town for the same scarce nurses. Vendors selling scheduling optimization, retention analytics, and agency-spend reduction should treat Minnesota as a named-account market — 78 high-churn facilities plus a 23-building distressed tail is a complete territory list, and the September effective date gives the conversation a deadline.
Watch for: The wage floor's effective date next month and any operator commentary on compression — when the floor rises, the premium for experienced staff shrinks, and retention risk moves up the tenure curve. Watch too whether other workforce-standards-board states pursue the same federal Medicaid match; approval here is a template, and the next state to use it will be visible in a waiver filing before it is visible in the trades.