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Case Review Connections
A Newsletter for Healthcare Providers and Stakeholders Post-acute Care Edition Issue 42: November 2024 Do you receive the Case Review Connections newsletter? If not, sign up to ensure you receive important news and updates. |
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medicare open enrollment podcast
Please join us for our latest podcast with Kathy Madden from the Colorado State Health Insurance Assistance Program (SHIP) to learn about Medicare Open Enrollment.
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in this issue:
medical director's corner - 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.
health equity - language access
The Office of Minority Health has launched a language access plan to improve healthcare services for non-English speaking populations. This initiative is part of a broader effort to advance health equity by ensuring patients can access information in their preferred languages.
feedback
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Publication No. R146810-101-11/2024. This material was prepared by Acentra Health, a Medicare Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
