Providers should monitor the CMS denial reporting pilot launching in the second half of 2026, engage payer contracting strategies that reflect documented length-of-stay gaps, and track the WISeR prior authorization model as it expands beyond its initial six-state footprint.
Medicare Advantage Nursing Home Denial Practices Shredded by Appeals Contractor Research
Acentra Health, a Quality Improvement Organization serving 29 states, reviews 25,000 coverage appeals a month, the vast majority (83%) of them from skilled nursing patients.
Of those, leaders said Wednesday, a staggering 93% come from Medicare Advantage beneficiaries. That’s despite the fact that MA market penetration sits just below 52% in the QIO’s footprint. By comparison, only 7% of appeals come from individuals in Fee for Service Medicare.
— McKnight’s Long-Term Care News | January 23, 2026
Following Pilot, All Medicare Advantage Plans to Report Denials, Appeals Data
The Centers for Medicare & Medicaid Services will soon require all Medicare Advantage plans to submit data on initial coverage decisions and appeals they process.
The mandatory reporting would begin in 2027, but CMS is currently seeking insurance company volunteers to test a pilot starting in the second half of 2026.
The agency announced the effort in a Wednesday memo to Medicare Advantage plans, saying it would help streamline and improve the prior authorization process.
— McKnight’s Long-Term Care News | December 19, 2025
Medicare Advantage reform is sorely needed. MA is largely fraudulent, misleading, and costly both in spending and health. Chipping away at some of these pieces is for the good of the enrollees on their surfaces. But dig just a little deeper and the goal is clear.
— The Rowan Report | November 25, 2025
The Centers for Medicare and Medicaid Services (CMS) is launching a pilot program in six states to combat what they deem to be unnecessary treatments. Dubbed the Wasteful and Inappropriate Service Reduction (WISeR) Model, the voluntary program will launch in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington beginning January 1, 2026 and ending December 31, 2031. The program will use Artificial Intelligence (AI) and Machine Learning (ML) alongside human clinical review to “ensure timely and appropriate Medicare payment for select items and services.”
— The Rowan Report | September 4, 2025
Nearly 30% Of Nursing Homes Report Daily Medicare Advantage Denials, Delays
Medicare Advantage (MA) plans, which cover a majority of Medicare enrollees, are denying or delaying medically necessary post-acute care with alarming frequency.
That’s according to a survey from the American Health Care Association (AHCA), the nation’s largest nursing home provider association. The survey went to 363 nursing home providers in May 2025.
Of these providers, 37% reported they received weekly denials, 29% reported daily denials, and 17% reported monthly denials.
— Skilled Nursing News | August 28, 2025
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
