Featured Post

Medicare Advantage Prior Authorization Denials for Post-Acute Care Are Rarely Overturned

By Jermaine Piper, MPH, and Lane Koenig, PhD
June 11, 2024

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 […]

read more »