In addition to sagging Medicare Advantage payment rates, some skilled nursing providers also find themselves routinely doing battle to get paid for services they’ve already delivered.
The reimbursement challenges are affecting the bottom line, and in some places, they’re starting to limit patients’ access to care, operators and billing, experts warned. Not only are many seeing managed care plans increase payment denials, some observers say they’re often doing it without justifiable cause.
“The Medicare rates are going up, but the managed Medicare, the Medicaid Advantage payment rates are coming down for the same patient,” said Maureen McCarthy, RN, BS RAC-MT, president and CEO of Celtic Consulting, a clinical operations, reimbursement and revenue cycle firm in business for more than 20 years. “Now to add insult to injury, you have the denial issue. It’s getting significantly worse.”
MDS and billing teams “know the reasons they’re being denied payment are incorrect and don’t go along with CMS regulations or the RAI manual,” McCarthy added. But she said many claims teams she works with feel helpless to fight back.
“I think that’s what the insurers are counting on,” McCarthy said.
Last month, the Office of the Inspector General blasted Medicare Advantage organizations for improperly denying or delaying services to beneficiaries to increase profits. In a spot check of limited records, it found 13% of prior authorization requests that MA plans denied met Medicare coverage rules, and 18% of payment requests that were denied met Medicare coverage and billing rules.
Still, it’s unclear how often skilled nursing operators in particular are being denied, how many get those denials reversed upon appeal, or how much denied claims are costing them.
“I think we’d see significant issues in some areas of the country where Medicare Advantage penetration is huge,” McCarthy added. “It is insurer-specific. Some of them are fine; they follow the rules; they do the right thing. Some are not. It’s frustrating for the staff at the facility level. They’ve got enough going on.”
In Texas, where Medicare Advantage penetration is now above 50%, Cantex Continuing Care Network has seen MA reimbursement drop to 20% less per day than fee-for-service. At the same time, the company is spending more time and money on claims denials, managing partner Peter Longo told McKnight’s Long-Term Care News Wednesday.
“Our collections teams have ballooned just to collect at an acceptable level,” he said. “You have to eat your peas every day and just chip away at it. …Perseverance pays off. It’s not complicated, but it takes time.”
Cantex has 39 skilled nursing facilities and has the resources to go after hard-earned reimbursements. For some smaller providers, the issue is so costly it’s beginning to affect patient care.
“If I have a choice between Insurer A and Insurer B, and I know insurer B is going to give me a problem and deny payments on me, I’m not going to take that patient,” McCarthy said. “You’re looking at, what are the chances I’m going to get paid by this [insurance] provider rather than giving away care for free? They may be better off taking a straight Medicaid patient than a Medicare Advantage patient because at least they know there’s guaranteed payment there.”
In some cases, McCarthy said, nurse case managers working on behalf of insurers are misinterpreting Medicare guidelines. She frequently has seen patients denied for COVID coverage; isolation services denied if patients weren’t in isolation for a full 14 day-look back period; insurers pressuring providers to change primary diagnosis codes to match a previous hospital diagnosis; and denial over a late MDS signature, which is not a payment issue but a regulatory issue as long as the provider submits for payment within an established window.
Back to the mouth that bit you
“They’re looking for sort of loopholes to not cover the patients,” McCarthy said. “You go to a Level, Level 2, Level 3 appeal within that Medicare Advantage payer and then there’s no other option for them. It’s, ‘Who do I go to? How do I get this into the five-step appeal process?’ …No one’s really looking at it.”
Where that Medicare appeal process has a clear path to an administrative law judge under fee for service, providers are desperate for the Centers for Medicare & Medicaid Services to issue rules that help them better navigate MA denials and get cases before an outside determiner. For now, “your hand is going right back to the mouth that bit you,” McCarthy noted.
She presented on the issue at the American Association of Post-Acute Nursing’s April conference and has fielded increasing calls on the issue since then.
One major issue that could lead to additional consequences: Insurers’ case managers sometimes exert pressure on facility staff to change case mix calculations under the Patient Driven Payment Model or even primary diagnosis codes to match what the payer is willing to cover. In one glaring example, McCarthy said she worked with a facility that wanted to downcode a patient’s hip fracture care to abdominal pain, either stripping the patient of needed care or leaving the skilled nursing provider holding the bag.
“The coordinators are so busy as it is, they’re being pulled to the floor because patient care comes first, so they’re very much willing at this point in time to give up the fight and just move on with their job,” she said. But she advises clients to never falsify diagnoses at a payer’s request; doing so is a federal offense that could result in substantial fines — to the facility and the insurer.
McCarthy also suggests raising awareness about poor pay practices by sharing contracts with the entire interdisciplinary team, not just admissions staff reviewing potential referrals; creating an easy-to-follow cheat sheet to remind staff which plans cover different therapy levels, medication and more; and including follow-ups on payment and denials in weekly care management and triple check meetings so all team members know when appropriate care ends up being rejected for reimbursement.