Medicare Advantage (MA) plans limit use of Medicare-covered services, in part, through pre-service (prior) authorization requirements for post-acute care (PAC), including care provided by a skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long-term acute care hospital (LTCH). If an MA plan denies a request for PAC, MA enrollees and their healthcare providers can challenge the denial by appealing the denial decision to the MA plan (requesting a redetermination). If the MA plan again denies the prior authorization request, the appeal is automatically sent to the CMS’ Independent Review Entity (IRE) as a Level 2 appeal.
In this blog, we report trends in Medicare’s IRE decisions related to institutional post-acute care (SNF, IRF, and LTCH). We examined IRE decisions between 2020 and quarter 1 (Q1) of 2024 using data from the Medicare Parts C & D IRE Decision Database.
IRE Determinations for Post-Acute Care. In Table 1, we document that very few appeals were overturned by the IRE for LTCH, SNF, and IRF care. The overturn rate was exceptionally low for LTCHs, less than 1 percent.
Table 1. Post-Acute Care and IRE Determinations (Between January 1, 2020 and March 31, 2024)
Source: KNG Health analysis of Medicare Parts […]
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Jermaine Piper is a Research Assistant in the Healthcare Reform and Payment Innovation Practice. Mr. Piper’s work focuses on conducting environmental scans on topics such as value-based payment programs, socioeconomic disparities in health care technology access, and financial indicators linked to hospital closures. In addition, Mr. Piper’s work includes data visualization for the construction of health sector chartbooks and quantitative cost-criterion analyses for new technology add-on payment (NTAP) applications for CMS. Furthermore, Mr. Piper also models payment adjustment factors for outpatient prospective payment systems (OPPS) and ambulatory surgical centers (ASC) settings for a state workers compensation program, utilizing proposed and final rules provided by CMS. Prior to joining KNG Health, Mr. Piper worked directly in health care as a Phlebotomist and Medical Laboratory Assistant for a local hospital. In this role, he provided direct patient care and facilitated the running of the hospital’s outpatient clinic and laboratory. Mr. Piper has a Master’s in Public Health with a concentration in Health Policy Analysis and Evaluation at the University of Maryland School of Public Health and has a BS in Public Health from the University of Maryland College Park. |
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Lane Koenig is President and Founder of KNG Health Consulting and Director of the Healthcare Reform and Payment Innovation Practice. He is a healthcare economist with over 20 years’ experience in the public and private sectors. As President of KNG Health Consulting, Dr. Koenig has overall responsibility for the quality and direction of KNG Health’s research. He serves as Project Director and Principal Investigator for many studies, particularly those related to healthcare reform proposals, healthcare provider payments, value-based purchasing, and delivery system innovations. With expertise on hospital and post-acute care payment and quality issues, his work regularly assesses the potential impact on hospitals and other providers of proposed legislation or regulations. He has assisted both industry and Federal and state governments in the development and assessment of healthcare provider payment policies and value-base purchasing initiatives. Prior to founding KNG Health in 2007, Dr. Koenig was the senior economist in the Office of Policy at the Centers for Medicare & Medicaid Services (CMS). Before joining CMS, Dr. Koenig was a Senior Scientist in the healthcare finance practice at The Lewin Group. Dr. Koenig has led over 100 quantitative and qualitative health policy and health economic studies and has published over 20 peer-reviewed studies in journals, such as Health Affairs, Health Services Research, and Medical Care. He graduated with Honors from the University of Florida, Gainesville and earned his PhD in Economics from the University of Maryland, College Park. |