Although focused on Medicaid, the report’s insights into the prevalence of denials, common reasons for disputes, and variations across state programs are valuable for facilities reliant on Medicaid reimbursement. By understanding these trends, skilled nursing facilities can strengthen documentation practices, proactively address potential red flags during utilization review, and develop effective appeal strategies to minimize payment disruptions and ensure access to care for Medicaid beneficiaries.
Chapter 2 looks at the monitoring and oversight of denials and appeals in Medicaid managed care and the beneficiary experience with the appeals process. Beneficiaries appeal few denials, and program operators do not collect comprehensive information about denials in Medicaid managed care. Federal rules do not require states to collect and monitor data needed to assess access to care, monitor the clinical appropriateness of denials, or require that states publicly report information on plan denials and appeals outcomes.
This chapter lays out the current federal requirements for the appeals process as well as for monitoring, oversight, and transparency; elaborates on state flexibilities within the current federal framework; and describes key challenges with the current structure. The Commission makes seven recommendations to improve the appeals process and enhance monitoring, oversight, and transparency efforts.
Read the Report to Congress on Medicaid and CHIP
Raible, M. (2024, July 1). Denials and Appeals in Medicaid Managed Care – MACPAC. MACPAC. https://www.macpac.gov/publication/denials-and-appeals-in-medicaid-managed-care-5/
Rowan, T. (2024, March 20). MedPAC exposes more Medicare advantage crimes. The Rowan Report. https://www.therowanreport.com/2024/03/20/medpac-exposes-medicare/
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
