McKnights Archives | Page 2 Of 2

Election Impact: Prior Authorization Reforms, Payer Denials and Delays

February 20, 2025

Our Take: More than 40 health insurers pledged to reduce prior authorization requirements under Trump administration pressure, though providers and patient advocates have raised questions about whether voluntary commitments will produce meaningful change.…

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MA News Roundup: Election Stakes, Insurer Conduct, and Policy Shifts Affecting Skilled Nursing Facilities

February 5, 2025

Our Take: Recent news documents a pattern of Medicare Advantage cost-shifting through patient disenrollment, new SNF co-pays, and unresolved prior authorization rules. The incoming Trump administration’s expected support for MA expansion leaves nursing…

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Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023

January 28, 2025

Our Take: A KFF analysis found that Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023 – roughly 125 times more than traditional Medicare. Skilled nursing facility stays were among…

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Do Medicare Beneficiaries Under Accountable Care or Medicare Advantage Use Lower Quality Nursing Homes?

December 31, 2024

Our Take: A study found that ACO-attributed Medicare beneficiaries were consistently the most likely to be admitted to high-quality SNFs, while Medicare Advantage enrollees were consistently the least likely. The research highlights how…

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Medicare Spending was 27% More for People who Disenrolled from Medicare Advantage than for Similar People in Traditional Medicare

December 6, 2024

Our Take: A KFF analysis of Medicare claims data finds that beneficiaries who disenrolled from Medicare Advantage and returned to traditional Medicare incurred 27% higher spending, an average of $2,585 more per person…

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Medicare Advantage and Managed Care Pressures on Skilled Nursing and Home Health: A Roundup

November 30, 2024

Our Take: Skilled nursing facilities are confronting a wave of prior authorization denials, administrative burdens, and managed Medicaid transitions that are compounding financial strain. Operators share ways to regain leverage with centralized claims…

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Medicare Advantage Plans With High Numbers Of Veterans: Enrollment, Utilization, and Potential Wasteful Spending

November 2, 2024

Our Take: A 2024 Health Affairs study documented that CMS paid over $1.32 billion to MA plans in a single year for VHA-enrolled veterans who used no Medicare services – exposing a structural…

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Unfulfilled Home Health Referrals Lead to Higher Mortality Among Medicare Advantage Members

July 9, 2024

Our Take: A study in The American Journal of Managed Care found that Medicare Advantage members referred to home health after hospitalization – but who never received those services – had significantly higher…

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Stop allowing MA plans to use AI to deny care without review, lawmakers urge CMS

June 25, 2024

Our Take: Fifty-two bipartisan lawmakers urged CMS to suspend Medicare Advantage plans’ use of AI tools for coverage decisions until a systematic federal review of their accuracy and discriminatory impact can be completed.…

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Medicare Advantage in Early 2024: Investor Fallout, AI Denials, Contract Complexity, and Operator Strategies

March 15, 2024

Our Take: As Medicare Advantage enrollment crosses the 50% threshold, the program is generating legal challenges over AI-driven denials, investor losses, and mounting operational complexity for skilled nursing providers. ▼ Understanding contract exclusions…

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CMS Advancing Interoperability and Improving Prior Authorization Final Rule (CMS-0057-F)

January 16, 2024

Our Take: CMS-0057-F requires MA plans and other payers to issue prior authorization decisions within 72 hours for urgent requests and 7 days for standard requests, while mandating FHIR-based APIs to share patient…

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MA Winter Roundup for SNFs: small gains and continued pressure

March 28, 2026

Our Take: Skilled nursing operators are seeing gains from proactive Medicare Advantage contract renegotiation; CMS is expands oversight of MA prior authorization and mandates the elimination of fax workflows by…

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Payer Roundup – March 2026

March 28, 2026

Our Take: KFF data confirms MA remains the highest-margin insurance segment, and regional plans are capturing enrollment gains as national insurers retreat. Federal enforcement of Medicare Advantage risk-adjustment fraud is…

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Contract Year 2027 Medicare Advantage and Part D Proposed Rule

March 14, 2026

Our Take: CMS’s CY2027 Medicare Advantage proposed rule streamlines Star Ratings and raises a red flag about dual-eligible enrollment in I-SNPs. The rule proposes that these nursing-home-focused plans may need…

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March 2026 Report to the Congress: Medicare Payment Policy

March 12, 2026

Our Take: MedPAC’s March 2026 report estimates Medicare is overspending by 14% on MA enrollees compared to FFS. This estimated $76 billion in higher costs is driven by favorable selection…

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First-Time Medicare Advantage Enrollees Demonstrate Increasing Demographic and Clinical Diversity

March 10, 2026

Our Take: First-time Medicare Advantage enrollees grew 85% between 2012 and 2022, and the population is now markedly more diverse, with dual-eligibles nearly doubling and Black beneficiaries rising from 13%…

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MA recipients, dual eligibles less likely to be discharged to highly rated post acute rehab

February 24, 2026

Our Take: A JAMA study of more than 44,000 stroke patients finds that MA and dual-eligible beneficiaries are significantly less likely to be discharged to highly rated SNFs than traditional…

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Study Finds Significant Medicare Advantage Disenrollment as Market Adjustments Continue

February 18, 2026

Our Take: A JAMA research letter finds that forced MA disenrollments jumped from under 1% historically to an estimated 10% in 2026, affecting approximately 2.9 million enrollees. Enrollees are losing…

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Medicare Advantage Enrollment Grew by About 1 Million People, Mainly Due to Special Needs Plans

February 15, 2026

Our Take: Medicare Advantage reached 35 million enrollees in 2026, but overall growth slowed to just 3%, with special needs plans accounting for 83% of all new enrollment as the…

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Study of Discharge Appeals in a Skilled Nursing Facility

February 1, 2026

JAMDA

Our Take: About 1 in 10 post-acute SNF patients filed a discharge appeal at a single California facility, with 77% ultimately losing. The patients who lost faced a 27.8% 30-day…

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MA Denial Proof Mounts as CMS Moves Toward Mandatory Reporting

January 30, 2026

Our Take: Provider surveys and research document the scale of the Medicare Advantage denial burden in skilled nursing. CMS is advancing mandatory denial reporting and prior authorization pilots, while legislative…

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Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024

January 28, 2026

Our Take: Medicare Advantage insurers made 53 million prior authorization requests in 2024, a 6% year-over-year increase. 7.7% of requests were denied, even as insurers publicly pledged to reduce administrative…

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CMS Proposes Nearly Flat Medicare Advantage Payment Rates for 2027

January 26, 2026

Our Take: CMS has proposed a 0.09% net average payment increase for Medicare Advantage plans in 2027, far below the 4% to 6% payers expected. MA payments stay essentially flat…

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Senate Report Finds UnitedHealth Turned Medicare Advantage Risk Adjustment into a Profit Strategy

January 12, 2026

Our Take: A 105-page Senate Judiciary Committee report, based on 50,000 pages of UnitedHealth’s own internal documents, concludes that the nation’s largest MA insurer built an engine to inflate risk…

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Payer Roundup – December 2025

December 31, 2025

Our Take: The December roundup documents an accelerating Medicare Advantage contraction with UnitedHealth projecting a 1 million-member enrollment drop in 2026. More than 40 health systems have severed MA contracts…

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Updates to Price Transparency Rules Pushed Out

December 19, 2025

Our Take: CMS has proposed significant updates to the Transparency in Coverage rules to restructure how hospitals and health plans publish machine-readable price files. These updates cut redundant data and…

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Insurers not fully complying with price transparency rules

December 9, 2025

Our Take: A peer-reviewed analysis of 2025 Transparency in Coverage files from Aetna, Cigna, and UnitedHealthcare finds significant gaps in completeness, particularly for hospital inpatient data. No insurer has been…

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Insurer use of algorithms cuts SNF length of stay

December 1, 2025

Our Take: A peer-reviewed study confirms that an MA insurer’s adoption of NaviHealth produced an immediate 13% decline in SNF length of stay, with stays over 30 days falling by…

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A Digest of How SNF Operators Are Navigating Medicare Advantage Complexity

November 30, 2025

Our Take: Growing financial and administrative pressures on skilled nursing facilities from Medicare Advantage is triggering broader industry education and sharing of best practices. Operators are managing MA with new…

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Prior Authorization Reform Heats Up

November 24, 2025

Our Take: At least 18 states enacted prior authorization reforms in 2025, outpacing federal regulators by requiring faster approval timelines, demanding evidence-based clinical review, and limiting AI-driven denials. These reforms…

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Chart Reviews Increase Payments to Medicare Advantage Insurers for 1 in 6 Enrollees

November 20, 2025

Our Take: Insurer-initiated chart reviews added diagnoses for 1 in 6 Medicare Advantage enrollees and generated an estimated $24 billion in additional federal payments to payer in 2023. Removals of…

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Complaints About Medicare Advantage Network Gaps Are Common. Federal Enforcement Is Rare

November 20, 2025

Our Take: CMS sent network adequacy violation letters to only five Medicare Advantage insurers over a six-year period and has never imposed civil monetary penalties, despite rampant complaints about provider…

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Push in Congress to Rein in Medicare Advantage

November 15, 2025

Our Take: Congress continued scrutiny of AI-driven denials and debating new prior authorization legislation. While these activities show continued momentum to reduce one of SNFs’ most persistent pain points –…

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Medicare Advantage Enrollment Among Long-Stay Nursing Home Residents Rose 183% From 2010 to 2023

November 14, 2025

Our Take: MA enrollment among long-stay nursing home residents tripled over 13 years, reaching 36.5% in 2023. But a recent sharp spike in MA disenrollment at the point of nursing…

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Provider-Led I-SNPs Reduce Nursing Home Hospitalizations but Raise Quality Questions

November 9, 2025

Our Take: Nursing homes that launch provider-led I-SNPs see hospitalizations fall and I-SNP enrollment surge. But the same financial incentives correlate with increased antipsychotic use, hypnotic drug use, and pressure…

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Medicare Advantage Reimbursement Structures Impact Home Health Delivery and Outcomes

November 6, 2025

American Journal of Managed Care

Our Take: When Medicare Advantage plans pay home health agencies on a per-visit basis and dictate visit counts and disciplines, patients face a 12% higher risk of inpatient transfer compared…

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