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Medicare’s annual open enrollment period (October 15 – December 7), is time for beneficiaries to take stock of their Medicare options for the upcoming calendar year – whether to choose  traditional (real) Medicare or a private insurance Medicare Advantage (MA) plan.

The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars to promote informed choice by beneficiaries. As the Center has discussed over the last few years, information about Medicare coverage options produced by the Medicare program is no longer neutral; instead, such information now actively promotes MA enrollment, and paints the MA program in the most favorable light, while downplaying its drawbacks. We have heard from a number of beneficiaries, advocates, and providers about their MA experiences. Last week we launched a series to highlight one of those first-hand reports, and to counter-balance MA industry advertising and Medicare program’s steering efforts. In today’s Alert, and upcoming CMA Alerts, we will write about other beneficiary, advocate, and provider experiences. These are all cautionary tales about Medicare Advantage that are not receiving adequate attention elsewhere.

We invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.


Case Study 1: MA Plan Prior Authorization Requirements Cause Problems in a Skilled Nursing Facility (SNF) Leading to Patient Re-Hospitalizations[1]

The SNF referenced here is a highly rated, privately owned, non-profit facility with almost 100 beds. The SNF serves traditional Medicare patients for an average of 14 to 21 days per admission. Typically, as long as the SNF documents that a patient has received necessary daily skilled care in the SNF after at least a 3-day inpatient hospital stay, Medicare covers the cost.

In addition to traditional Medicare, the SNF serves patients enrolled in multiple MA plans, but each MA plan typically authorizes SNF patient services for only 7 days, which is half to a third of the time an original Medicare patient stays in the SNF. During the 7 day MA plan authorized stay, each MA plan requires the SNF to provide extensive justification for continued services by giving documentation to the MA plan every 3 days for review.

Even when the MA plans allow a patient to receive 7 days of services, and the SNF then provides justification for MA plan patients to remain in the SNF longer than 7 days, multiple appeals to MA plans rarely result in additional authorized days. The SNF finds an occasional authorization by an MA plan beyond 7 days is clinically random – a patient they believe clearly needs continued services is denied, while a patient who is doing relatively better may be approved for several additional days. Further appeals for additional days, made to a Medicare Independent (medical) Review Entity (IRE, in this case KEPRO) are also frequently denied. Even when approved, MA plans do not always pay the SNF. One appeal to a Medicare Administrative Law Judge for a patient who was in the SNF from January 5, 2019 through January 31, 2019, was approved. On June 6, 2019, the judge ordered the MA plan to pay the SNF for the entire January stay. The MA plan has not paid the SNF for the approved services.

Last week 3 MA plan patients were discharged from the SNF although the SNF believed each patient was discharged prematurely. Each patient had only been authorized for 7 days of services at the SNF. Appeals for additional days in the SNF were unsuccessful. Without access to medically skilled care, all 3 patients have since been re-admitted to acute care hospitals.

The SNF is grappling with how to best provide care to MA plan patients. CMA has advised continued Medicare appeals by the SNF when it believes discharges are medically premature and continue to be Medicare coverable.

MA plans should not be allowed to override the expertise of the treating physician and the SNF at the expense of the patient’s health. MA plans should not be allowed to use prior authorization as a vehicle to deny necessary care.


Next Case

Case #2: Family History of Colon Cancer Should Increase the Frequency of Colonoscopies, but Ultimately the MA Plan, not the Treating Doctor, May Determine When Procedures Will Occur

November 14, 2019 – K. Holt

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[1] Factual recount as reported to CMA on October 29, 2019. The names of the beneficiaries, provider, and MA plans have been withheld for privacy purposes.

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