Medicare Advantage documents

Several large insurance providers are expanding their Medicare Advantage plans to new states and hundreds more counties, effective in 2023, adding pressure on skilled nursing operators as enrollment booms.

Aetna, with 3.2 million MA members, is adding nearly 200 counties, while Cigna will grow its geographic footprint by 22%. UnitedHealthGroup, Humana and Elevance Health also increased their presence, according to various reports..

A Kaiser Health News news report Tuesday highlighted complaints that nursing home patients using MA have been released before they were well enough to go home, and in fewer days than Medicare covers.

MA can be a headache for some facilities, acknowledged Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care.

“Forty-eight percent of (Medicare) beneficiaries are currently enrolled (in MA) and that will only grow and grow quickly,” Morton told McKnight’s Long-Term Care News. “MA plans put LTC through hoops and hurdles to manage the patients; some LTC facilities make it work, others spend a lot of their resources in time and money dealing with the MA plan, to appeal certain denials from the MA Plan, or provide care a certain way the MA plan wants the patient’s care to be conducted or shortened.”

More MA means more prior authorization, the practice of obtaining an insurer’s approval of care before it is performed. Its pros and cons were detailed in a viewpoint published Monday in JAMA. Author Kelly E. Anderson, MD, MPP, made suggestions to improve prior authorization, which is beginning to be used more in traditional Medicare.

Anderson mentioned the administrative effort Morton alluded to. Further, 93% of physicians reported care delays and 82% reported care abandonment (either not initiating or not continuing the recommended treatment) due to prior authorization policies.

“Although using prior authorization to curb unnecessary services may reduce waste and slow the growth of healthcare spending, a serious consequence is that necessary medical services may also be limited,” Anderson wrote. “This may lead to an increase in expensive downstream care and disparities in access.”

Anderson noted that there is a bill in each chamber of Congress intended to modernize and monitor the use of prior authorization. She called for the following improvements:

*Plans should use an electronic-based prior authorization process with time-bound requirements for initial and appeal decisions;

*Plans should be mandated to report guidelines used to make prior authorization decisions and seek input from respective medical societies and stakeholder groups on an annual basis;

*The relative benefits and costs of prior authorization should be reviewed by the CMS at the procedure level;

*MA insurers should report approval and denial rates annually to the CMS based on “beneficiary sociodemographic characteristics and by procedure type so that the CMS can monitor whether prior authorization policies may be increasing disparities in access to care

*Drawing upon MA insurer–submitted data on denial rates, the CMS should audit the denials of plans with high-denial rates.

“Approximately 70% of Medicare Advantage enrollees are in plans that require prior authorization to receive care in a skilled nursing facility,” Anderson told McKnight’s Long-Term Care News. “Improving Medicare Advantage prior authorization, by creating a standardized electronic process, shortening timelines for prior authorization reviews, and increasing the Centers for Medicare & Medicaid Services’s oversight of the process, can help improve beneficiary access to long-term care.”

Both federal watchdog agencies and individual skilled nursing providers have opined the frequency of MA denials for justified and allowable services, particularly for seniors. They also complain that there is no clear and easy process to appeal denials.

Morton is optimistic about the standardized electronic process improvement. She said the House passed a bill (HR 3173) calling for it.

“The Senate has not passed it yet, but I am betting it is included in the last healthcare package that Congress considers in the lame duck session in November or December,” she said.

Morton said mandating the creation of a standardized electronic process for prior authorization inside an MA plan could reduce the variation in steps that a nursing home has to go through to get a particular service approved by the plan for the patient. That could save time and some resources for facilities. 

“What we are not so sure about with the legislation, is whether every MA plan has to use the same standardized prior authorization process,” Morton said.  “So, if they each can have their own standardized process, we could have a situation where a nursing home is facing 10 different prior authorization processes for each of the 10 MA plans that manage/cover/pay for 10 patients in the nursing home. The bill is just not written specific enough to know at this stage.”