Case Review Connections

Medical Director's Corner

Written by Jessica Whitley, MD, MBA

Our Appeals Department plays an essential role in safeguarding Medicare beneficiaries' rights, particularly those in skilled nursing facilities (SNFs). Medicare beneficiaries often face appeals related to the termination of services when they or their representatives dispute decisions to end Medicare-covered services. A recent data analysis from the first quarter of our contract (May through July 2024) highlighted significant trends in appeals within SNFs. Notable differences were revealed between Medicare Advantage (MA) plan enrollees and those under traditional Fee-for-Service (FFS) Medicare.

High Prevalence of Appeals in Skilled Nursing Facilities

A substantial 82% of appeals originate from the SNF setting, underscoring the critical importance of addressing issues related to Medicare coverage and services within SNFs. This data reflects the challenges faced by beneficiaries and the need for continuous oversight and intervention to ensure appropriate coverage decisions.

Discrepancies Between Medicare Advantage and Fee-for-Service Appeals

One of the most striking findings was that 88% of all SNF appeals come from MA plan beneficiaries, even though only 52% of Medicare beneficiaries are enrolled in such plans. This disparity suggests a higher frequency of Notices of Medicare Non-Coverage (NOMNC) being issued by MA plans compared to those serving traditional FFS beneficiaries.

The initial peer reviewer disagreement rate on NOMNCs is slightly higher for MA beneficiaries (42%) than for FFS beneficiaries (37%), highlighting potential challenges in coverage determinations for those enrolled in an MA plan. Moreover, repeat NOMNCs issued within the same SNF stay are more common among MA beneficiaries, with 24% of total MA appeals resulting from repeat NOMNCs compared to just 10% for FFS beneficiaries.

As we continue to monitor these trends, Acentra Health is committed to advocating for Medicare beneficiaries and ensuring that all individuals receive the coverage and care they deserve. By addressing these challenges, we can work toward a more equitable healthcare system that supports the needs of all Medicare beneficiaries, regardless of their plan type.

Skilled Nursing Facility (SNF) Appeals Trends Webinar

In August, Acentra Health's Chief Medical Officer, Dr. Whitley, presented at a webinar, Unlocking Insights - Exploring Medicare Skilled Nursing Facility Appeal Trends and Lessons Learned. This presentation highlighted key takeaways from recent SNF appeal data, offering valuable insights for healthcare professionals. The presentation slides, recording, and Q&A session are now available on our Webinar Updates page.

Transition From Part D To Part B Of Antiretroviral Drugs To Prevent HIV

Recently the Centers for Medicare & Medicaid Services (CMS) advised pharmacies and other stakeholders to prepare for the upcoming shift in coverage for HIV prevention drugs (pre-exposure prophylaxis, or PrEP) from Medicare Part D to Medicare Part B. This change took effect in late September 2024 once the final National Coverage Determination (NCD) was released. More details about this transition can be found on the CMS website under PrEP for HIV & Related Preventive Services.

 

Feedback

We value your feedback. Please let us know if there is any content that you would like to see covered in our stakeholder/provider newsletter by emailing QIOCommunications@acentra.com.