Operators with data-driven contracting approaches, proactive prior authorization workflows, and value-based care partnerships will be better positioned to protect revenue in this environment.
How Skilled Nursing Providers Are Rising to 3 Top Reimbursement Challenges
Ignite has a vice president of managed care who sits down with Medicare Advantage providers and negotiates new contracts, Rainey said. Many plans offer higher reimbursement for certain conditions and treatments, such as bariatrics and in-house dialysis, but the goal is to make sure the base payment rate for other services is aligned with the Patient Driven Payment Model (PDPM). Even so, it’s likely that the rates won’t equal the full PDPM rate.
Meaningful negotiations with a managed care company depends on having data, she said.
— Skilled Nursing News, November 26, 2025
Part of the problem with Medicare Advantage plans is that they are currently allowed too long of a window of time to make preauthorization decisions. According to the final rule, starting Jan. 1, 2027, payers must make decisions within 72 hours, or seven days for regular authorizations on the commercial side, and the current administration is trying to shorten it, said Bevey Miner, EVP of health care strategy and policy at Consensus.
— Skilled Nursing News, October 24, 2025
“[MA] is not as attractive, maybe, as it once was. And I think because of that, you’re going to see a shift maybe either in how beds are available – maybe it’s more semi private beds. Unfortunately, private rooms are really what the short-stay residents want and need,” Hart said.
Moreover, the MA margins are somewhat comparable to long-stay residents, which are typically covered by Medicaid, Hart said.
— Skilled Nursing News, October 10, 2025
How to Not Lose $9,325 in Reimbursement
We know that managed care health plans usually reimburse significantly less than Medicare fee-for-service. A provider’s first priority is to secure the most optimal contract terms with managed care health plans. It’s a vital step for setting reimbursement as close as possible to FFS reimbursement, whether that be through rates or a combination of rates and exclusions.
— McKnight’s Long-Term Care News, October 1, 2025
Appeals is a good area [to focus on]. I won’t name the name, but let’s say they’re a national company that reviews for a lot of skilled care. We were on a call with them, and it was like, “Well, wait a minute, you’re getting all these appeals overturned.” It’s because we know what we’re arguing for. We did have a little bit longer length of stay by a day or so, but [we also had] significantly lower return to hospital rates. So we added a day in your Medicare Advantage world, but it definitely improved the overall episode of care for that patient or resident. So I think it’s just really understanding [the big picture].
— Skilled Nursing News, September 24, 2025
Data, Persistence Are Key When Working with MA Plans, Enhabit’s Jacobsmeyer Says
In recent years, the provider has relied on a payer innovation strategy to drive better reimbursement rates. This kind of strategy involves leveraging data to convince MA plans to pay more for services. Jacobsmeyer reiterated the importance of strong data to support home health’s value proposition.
“Data is your biggest friend: data from your quality side, your timeliness of care side, how many of the members you are taking care of, and then on the back end understanding how long it is taking you to get paid,” Jacobsmeyer explained. “Data is going to direct every conversation.”
— McKnight’s Home Care, September 22, 2025
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
