SNFs with Medicaid managed care contracts should not assume that state agencies are monitoring inappropriate denials — MACPAC confirms that federal rules don’t require it. Developing facility-level data on denial rates and appeal outcomes by plan gives SNFs the evidence needed to renegotiate contracts, escalate concerns to state regulators, and build the case for clinical appropriateness.
Denials and Appeals in Medicaid Managed Care
Chapter 2 looks at the monitoring and oversight of denials and appeals in Medicaid managed care and the beneficiary experience with the appeals process. Beneficiaries appeal few denials, and program operators do not collect comprehensive information about denials in Medicaid managed care. Federal rules do not require states to collect and monitor data needed to assess access to care, monitor the clinical appropriateness of denials, or require that states publicly report information on plan denials and appeals outcomes.
This chapter lays out the current federal requirements for the appeals process as well as for monitoring, oversight, and transparency; elaborates on state flexibilities within the current federal framework; and describes key challenges with the current structure. The Commission makes seven recommendations to improve the appeals process and enhance monitoring, oversight, and transparency efforts.
— MACPAC, March 2024
Raible, M. “Denials and Appeals in Medicaid Managed Care.” MACPAC, Mar. 2024. https://www.macpac.gov/publication/denials-and-appeals-in-medicaid-managed-care-5/.
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
