{"id":180423,"date":"2025-08-27T18:49:12","date_gmt":"2025-08-27T18:49:12","guid":{"rendered":"https:\/\/www.europesays.com\/us\/180423\/"},"modified":"2025-08-27T18:49:12","modified_gmt":"2025-08-27T18:49:12","slug":"medicare-advantage-denials-of-post-acute-care-occur-daily-weekly-for-two-thirds-of-nursing-homes","status":"publish","type":"post","link":"https:\/\/www.europesays.com\/us\/180423\/","title":{"rendered":"Medicare Advantage Denials of Post-Acute Care Occur Daily, Weekly for Two-Thirds of Nursing Homes"},"content":{"rendered":"<p><strong>\u200b\u200bWASHINGTON, D.C. \u2013<\/strong> With more than half of all eligible Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan, a <a href=\"https:\/\/www.ahcancal.org\/News-and-Communications\/Fact-Sheets\/FactSheets\/Provider-Insights-Medicare-Advantage.pdf\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"60b7cbf17788425491b2d083\" target=\"_blank\" rel=\"noopener\">survey \u200b<\/a>from the American Health Care Association (AHCA) finds that MA plans are denying or delaying medically necessary post-acute care, often against medical professionals\u2019 recommendations, on a daily and weekly basis.\u00a0\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>The results of the survey, conducted by AHCA in May 2025 of 363 nursing home providers, adds to existing <a href=\"https:\/\/www.hsgac.senate.gov\/wp-content\/uploads\/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf\" target=\"_blank\" rel=\"noreferrer noopener\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"60b7cbf17788425491b2d083\">research<\/a> that finds post-acute care is disproportionately impacted by MA prior authorizations. Additional <a href=\"https:\/\/www.kff.org\/medicare\/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"60b7cbf17788425491b2d083\">research<\/a> has also found that while a small share of denied prior authorization requests are appealed, most appeals are partially or fully overturned.\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>\u201cThis constant hoop jumping is resulting in too many skilled nursing patients being discharged too soon against medical advice, threatening their recovery,\u201d <strong>said Clif Porter, president and CEO of AHCA<\/strong>. \u201cWe want to make sure Medicare Advantage plans are providing the therapy benefits our seniors were promised and are not leaving important\u2014sometimes life-saving\u2014medical decisions to AI or insurers without appropriate guardrails and oversight. There is a better way to approach coverage decisions: where we put patients and their care team at the center of every decision.\u201d\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>Highlights from the survey include:\u00a0<\/p>\n<p>\u00a0<\/p>\n<p><strong>Denials or delays of medically necessary post-acute care by Medicare Advantage occur daily and\/or weekly for two-thirds of skilled nursing providers.<\/strong>\u00a0<\/p>\n<ul role=\"list\">\n<li aria-setsize=\"-1\" data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"24\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;multilevel&quot;}\" data-aria-posinset=\"1\" data-aria-level=\"1\" role=\"listitem\">Providers report denials or delays of post-acute care services:\u00a0<\/li>\n<ul>\n<li aria-setsize=\"-1\" data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"24\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;multilevel&quot;}\" data-aria-posinset=\"1\" data-aria-level=\"1\" role=\"listitem\">Weekly (37 percent)<\/li>\n<li aria-setsize=\"-1\" data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"24\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;multilevel&quot;}\" data-aria-posinset=\"1\" data-aria-level=\"1\" role=\"listitem\">Daily (29 percent)\u00a0<\/li>\n<li aria-setsize=\"-1\" data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"24\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;multilevel&quot;}\" data-aria-posinset=\"1\" data-aria-level=\"1\" role=\"listitem\">Monthly (17 percent)\u00a0<\/li>\n<\/ul>\n<\/ul>\n<p>\u00a0<\/p>\n<p><strong>The majority of providers have encountered situations in which a resident\u2019s coverage is pulled prematurely against the advice of the resident\u2019s medical care team:<\/strong>\u00a0<\/p>\n<ul role=\"list\">\n<li aria-setsize=\"-1\" data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"25\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"1\" data-aria-level=\"1\" role=\"listitem\">More than two-thirds (67 percent) of providers have encountered situations in which a MA plan pulled coverage for a resident against medical advice.\u00a0\u00a0<\/li>\n<\/ul>\n<p>\u00a0<\/p>\n<p><strong>More than half of providers report that denials for care are frequently overturned once appealed, indicating a flawed or unfounded initial denial.\u00a0<\/strong>\u00a0<\/p>\n<ul role=\"list\">\n<li aria-setsize=\"-1\" data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"26\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"1\" data-aria-level=\"1\" role=\"listitem\">Providers report that initial claims denials are reversed upon appeal always (3 percent) or sometimes (54 percent) compared to rarely (32 percent).\u00a0<\/li>\n<\/ul>\n<p>\u201cRecent commitments from many insurance providers to do better on prior authorizations are encouraging, but these survey results remind us that there is still a long way to go, especially in post-acute care,\u201d <strong>said Nisha <\/strong><strong>Hammel, Vice President of Reimbursement Policy &amp; Population Health at AHCA<\/strong>. \u201cWe want plans that are working well to continue to serve seniors, and we want seniors to have choices that work for their needs. We encourage federal policymakers to advance opportunities to enhance Medicare Advantage, so we can all realize its potential.\u201d\u00a0\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>AHCA\u2019s May survey of providers was <a href=\"https:\/\/www.ahcancal.org\/News-and-Communications\/Press-Releases\/Pages\/New-Survey-Highlights-Devastating-Impact-of-Medicaid-Reductions-on-Nursing-Homes.aspx\" target=\"_blank\" rel=\"noreferrer noopener\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"60b7cbf17788425491b2d083\">released<\/a> in part earlier this year during the budget reconciliation debate. The survey asked providers about several key policy issues related to The Better Way, AHCA\u2019s forward-looking policy agenda to deliver bold solutions for quality long term and post-acute care. One of the policy priorities is \u201cReaffirming the Promise of Medicare Advantage,\u201d offering several recommendations for alignment among providers, residents, policymakers, and the public. Learn more about The Better Way <a href=\"https:\/\/www.ahcancal.org\/News-and-Communications\/Fact-Sheets\/FactSheets\/AHCA-The-Better-Way.pdf\" target=\"_blank\" rel=\"noreferrer noopener\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"60b7cbf17788425491b2d083\">HERE<\/a>.\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>Access the Provider Insights: Medicare Advantage report <a href=\"https:\/\/www.ahcancal.org\/News-and-Communications\/Fact-Sheets\/FactSheets\/Provider-Insights-Medicare-Advantage.pdf\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"60b7cbf17788425491b2d083\" target=\"_blank\" rel=\"noopener\">HERE<\/a>\u200b\u200b\u200b.\u00a0\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"\u200b\u200bWASHINGTON, D.C. \u2013 With more than half of all eligible Medicare beneficiaries enrolled in a Medicare Advantage (MA)&hellip;\n","protected":false},"author":3,"featured_media":180424,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35],"tags":[101911,210,1141,1142,28533,67,132,68],"class_list":{"0":"post-180423","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health-care","8":"tag-ahca-ncal-updates","9":"tag-health","10":"tag-health-care","11":"tag-healthcare","12":"tag-medicare-advantage","13":"tag-united-states","14":"tag-unitedstates","15":"tag-us"},"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@us\/115102231104088160","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/180423","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/comments?post=180423"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/180423\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media\/180424"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media?parent=180423"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/categories?post=180423"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/tags?post=180423"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}