For skilled nursing facilities, the article’s case for greater transparency and accountability in MA denial practices directly implicates the prior authorization denials that delay or block post-acute admissions.
SNFs operating under MA contracts should track denial rates and appeal outcomes by plan, as this data becomes increasingly important for payer negotiations and for identifying plans with inappropriate utilization management practices. The viewpoint’s recommendation to factor denial rates into CMS Star Ratings could create new leverage for facilities to hold underperforming payers accountable.
Coverage Denials in Medicare Advantage—Balancing Access and Efficiency
Each year, millions of claims for medical services are denied by health insurance plans. Many denials may be justified as a necessary strategy to reduce wasteful spending from low-value care. However, denials may also delay diagnosis and/or treatment for patients, and appealing denials contributes to clinician workload and burnout. This tension is apparent in the Medicare program, where denials affect millions of beneficiaries who enroll in Medicare Advantage (MA). Although MA plans are required to cover the same services as traditional Medicare, these private plans are allowed to leverage utilization management tools, such as prior authorization, that traditional Medicare rarely uses. In 2021, MA plans denied approximately 6% of the 35 million prior authorization requests submitted.
— JAMA Health Forum, 1 March 2024
Gondi, Suhas, et al. “Coverage Denials in Medicare Advantage—Balancing Access and Efficiency.” JAMA Health Forum, 1 Mar. 2024. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815743.
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
