Case Review Connections

Medical Director's Corner

Written by Jessica Whitley, MD, MBA

Aligning Coverage Decisions with Clinical Need in Skilled Nursing Care

“Timely, individualized decision-making is essential to supporting safe care transitions for Medicare beneficiaries recovering in skilled nursing facilities.”

Ensuring safe, clinically appropriate care transitions is essential for Medicare beneficiaries recovering in skilled nursing facilities (SNFs). To better understand trends related to SNF appeals, Acentra Health recently completed a Centers for Medicare & Medicaid Services (CMS)-approved focused study examining the issuance of Notices of Medicare Non-Coverage (NOMNCs) for Medicare Advantage (MA) beneficiaries and the potential impact on care transitions.

Within Acentra Health service regions, MA beneficiaries account for approximately 52 percent of the Medicare population, yet they represent 93 percent of SNF-based appeals. This discrepancy prompted a closer review to better understand the clinical circumstances surrounding these appeals.

Focused Review of High-Risk Beneficiaries

The study examined appeals involving beneficiaries identified as being at higher risk for functional decline. Reviews were conducted by experienced physical and occupational therapists.

• For this analysis, high-risk beneficiaries were defined as individuals who were able to ambulate more than 100 feet before hospitalization, but were able to ambulate fewer than 50 feet at the time of appeal.

Key Findings

The review identified several notable trends:

• 92 percent of beneficiaries continued to require skilled care at the time the NOMNC was issued.
• 72 percent were identified as being at an elevated risk of decline or hospital readmission if discharged at that point in care.

These findings suggest that, in many of the reviewed cases, NOMNC issuance may not have fully reflected the beneficiary’s functional status or ongoing skilled care needs.

Additional patterns were observed:

• NOMNCs were frequently issued around day 15 of the SNF stay, regardless of documented progress.
• Some beneficiaries received multiple NOMNCs during a single episode of care.
• NOMNC timing did not consistently correlate with clinical acuity or risk level.

Care Planning and Documentation Opportunities

The review also identified opportunities to strengthen care planning practices:

• Nearly 40 percent of beneficiaries did not have individualized goals documented at admission.
• Fewer than half had goals updated to reflect changes in clinical or functional status.

Individualized and regularly updated care plans are essential to supporting appropriate rehabilitative care and informed discharge decisions.

Actionable Recommendations

For MA Plans

• Align NOMNC issuance with the beneficiary’s clinical condition and functional status.
• Follow the CMS guidance for repeat appeals, including documentation of clinical changes after favorable quality improvement organization (QIO) decisions.
• Collaborate with SNFs to support interdisciplinary discharge planning.

For SNFs

• Establish individualized, achievable goals at admission.
• Update plans of care based on beneficiary progress.
• Begin discharge planning early with interdisciplinary involvement.
• Maintain clear and comprehensive documentation of clinical and functional status.

Moving Forward

Effective care transitions require collaboration, clinical alignment, and strong documentation. By working together, MA plans and SNFs can support appropriate utilization, reduce unnecessary appeals, and promote safe, patient-centered transitions of care.

Appeals Update

We held a webinar on January 21, 2026, related to our focus study project, Medicare Advantage Plan Appeals in Skilled Nursing Facilities. Our presenters were Jessica Whitley, MD, MBA - Chief Medical Officer, Angeline Brunetto, MD, MBA, CPE, CRC, Associate Medical Director, Appeals.

This focused review examined the use of NOMNCs by MA plans in SNFs. We explored key data points, highlighted systemic challenges, and most importantly, discussed actionable recommendations. Visit our website to view the slides and the recorded webinar.

Acentra Health Resources - Beneficiary Complaint Podcast

Acentra Health has a new podcast episode focusing on the beneficiary complaint process. The two hosts were our Operations Manager, Carla Boguslawski, MBA, MEd, BS, and Melinda Burk, LPN, Clinical Review Nurse. This has useful information for Medicare beneficiaries that may have concerns about the health care they received.

CMS Quality Conference - March 16-18, 2026

The CMS Quality Conference brings together leaders, providers, researchers, advocates, and partners who are all committed to improving healthcare quality and outcomes. This year’s theme, Make America Healthy Again: Innovating Together for Better Health, focuses on bold ideas and teamwork to create real change.

Virtual attendance is available. For more information or to register, visit CMS Quality Conference 2026.

Rural Health Updates

CMS announced $50 billion in funding for the Rural Health Transformation Program. This is a nationwide initiative established under Public Law 119-21 to strengthen and modernize rural health care in all 50 states.

• To assist with this initiative, CMS has announced the establishment of the Office of Rural Health Transformation (ORHT) within the Center for Medicaid and CHIP Services (CMCS).

Beginning in 2026, each state will receive first-year awards averaging about $200 million, with amounts ranging from roughly $147 million to $281 million. The investment aims to expand access to care for the more than 60 million Americans living in rural areas by:

• Improving primary, preventive, maternal, behavioral, and emergency services
• Strengthening the rural health workforce
• Modernizing facilities and technology
• Supporting innovative, community-based care models

Federal leaders emphasized that the program is designed to give states and local providers greater control to deliver high-quality, affordable care closer to home.

Additional information on the Rural Health Transformation Program is available at http://www.cms.gov/RHTProgram. CMS also put out a press release with the award amounts.

Feedback

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