For skilled nursing facilities, this regulatory backdrop reflects mounting pressure on the MA payer practices that most directly affect post-acute admissions, denial rates, and reimbursement.
As federal agencies intensify scrutiny of MA prior authorization denials and overbilling, SNFs should anticipate potential shifts in plan behavior affecting coverage decisions for post-acute stays. Strengthening utilization management documentation and actively appealing inappropriate denials positions facilities to protect revenue during this regulatory transition.
Medicare Advantage: Growth Amidst Mounting Scrutiny
The Medicare Advantage Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. The Government Accountability Office called on the Centers for Medicare & Medicaid Services to monitor “disenrollment of MA beneficiaries in the last year of life, validate MA-provided encounter data, and strengthen audits used to identify and recover improper payments to MA plans.” The House Subcommittee on Oversight and Investigations of the Committee on Energy & Commerce, dedicated a hearing to “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans.” In addition, a recently conducted audit of the Office of the Inspector General of the Department of Health and Human Services raised concerns over “denials of prior authorization requests” and “beneficiary access to medically necessary care.” In this article we consider the backdrop for the growing scrutiny of the MA program and the implications thereof to its future trajectory.
— Journal of the American Board of Family Medicine, 18 October 2023
Adashi, Eli Y., Daniel P. O’Mahony, and I. Glenn Cohen. “Medicare Advantage: Growth Amidst Mounting Scrutiny.” Journal of the American Board of Family Medicine, 18 Oct. 2023. https://www.jabfm.org/content/36/6/1062.
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
