The Center for Medicare Advocacy conducted a short survey of skilled nursing facilities (SNFs) in April 2022 after hearing an increasing number of alarming experiences with Medicare Advantage (MA) from CT beneficiaries and SNFs. The goal of the survey was to determine the nature and scope of issues, if any, SNFs were facing with MA plans. The survey was disseminated by Connecticut Association of Healthcare Facilities/Connecticut Center for Assisted Living and LeadingAge Connecticut. Of the state’s 211 SNFs, 31 facilities responded (27 for-profit and 4 non-profit), amounting to approximately 15% of the state’s SNFs.
- Overall: Almost two-thirds (65%) of respondents indicated “Yes” their facility had “consistent” issues with a Medicare Advantage plan (e.g., denials of coverage and prior authorization delays).
Of those respondents who replied “Yes”:
- 60% contended that the MA issues impacted the ability of staff to provide quality care to nursing home residents.
- 75% answered that the issues with MA plans have increased in the past twelve months.
- Issues brought up independently in the survey by the SNFs
Prior Authorization (45% of respondents), issues such as:
- Prospective patients sitting in the hospital
- Delays in authorization
- No availability on weekends to provide prior authorizations
- “We are seeing consistent delays in hospital authorizations with Wellcare, Aetna, and UnitedHealthcare. It has taken upwards of 3 or more days to obtain authorization.” (SNF A)
- “Prior authorization delays for admissions from hospitals. Sometimes up to 48-72 hours.” (SNF B)
Denials of Coverage (75% of respondents), issues such as:
- Not complying with the 48-hour requirement for a NOMNC
- Cut from skilled care, even though staff is documenting skilled needs. Potentially leading to unsafe discharge.
- “Constant NOMNC. If a member appeals and wins the appeal, the MA just issues another NOMNC to start the process over again.” (SNF C)
- “Aetna has an in-house policy of retro denials. They authorize and then they will recoup payments … and the facility is held liable.” (SNF D)
- “Patients are having their benefit cut before they are ready to return home, and are left to privately pay for room and board or have an unsafe discharge.” (SNF C)
- “These plans either do not comply with the 48 hours of notice – or – and more importantly issue denials in situations when we know Medicare would have allowed more time.” (SNF E)
Not Following Medicare Coverage Criteria (25% of respondents), issues such as:
- “Staff are educated on Medicare skilled criteria, and Medicare Advantage plans do not follow this. Residents present as needing skilled care and staff is forced to discharge them home, perhaps unsafely, because there is no payor.” (SNF F)
August 18, 2022 – C. St. John