Medicare Advantage documents
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Skilled nursing providers are demanding changes after a new federal report found that Medicare Advantage organizations (MAOs) have improperly denied or delayed services to beneficiaries to increase profits. 

The experience is all too common for SNFs that have struggled to admit some residents due to the issue in recent years.

“Every time we have a resident referral who has an MA plan, we know we are in for a fight,” said Rick Holloway, administrator of the Idaho State Veterans Home in Boise. “There has never been an easy admission of a resident who has MA.” 

The report was released Thursday by the Office of Inspector General. The OIG accused MAOs of sometimes delaying or denying Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. 

The report also found that MA organizations denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Post-acute facilities were among the healthcare services often involved in denials that met Medicare coverage rules, the OIG said. 

“In some cases, we have had preliminary approvals, then retroactive denials resulting in months of data submissions and appeals to get paid,” Holloway told McKnight’s Long-Term Care News on Friday.   

Call for Medicare reform

He added that it is “well known” in the industry that a resident who is covered under MA will have a length of stay between seven and 20 days, and rarely do providers get approved for therapy beyond that. He said that considering many residents who are admitted directly from the hospital are too sick and frail to start therapy immediately, his facility usually can only get 10 days of therapy before it is forced to discharge.

“There has to be something Medicare can do to stop these MA plans from profiting on the backs of our precious elderly,” Holloway said. 

“Many skilled facilities have the same experience with MA programs.  I truly think they give the policyholders an incorrect picture of what they cover,” he later added. 

Although some of these practices are longstanding, now that Medicare Advantage plan penetration is growing so rapidly, it is more important than ever that these plans apply the same coverage rules as traditional Medicare, emphasized Brian Ellsworth, vice president for public policy and payment transformation at Health Dimensions Group. 

“When providers have appropriate documentation, they should get paid with minimum hassle factor. Unfortunately, this has not always been the case,” Ellsworth told McKnight’s Friday. 

The OIG also found 13% of prior authorization requests that MA plans denied met Medicare coverage rules. In addition, it determined that 18% of payment requests that were denied met Medicare coverage and billing rules.

The Center for Advocacy said that there’s reason to believe the report’s estimates of MA denial rates are on the conservative side, given recent findings from artificial intelligence-driven, decision-making tools show even higher rates. 

“The use of these post-acute care management companies and their AI-driven decision-making tools, in our experience, has led to frequent and repeated denials of care — sometimes every few days — even when individuals still require medically necessary SNF care,” said David Lipschutz, the center’s director.