Analysis & Research

Medicare Spending was 27% More for People who Disenrolled from Medicare Advantage than for Similar People in Traditional Medicare

December 6, 2024

GAINING CLARITY: This must-read for skilled nursing facilities dissects key trends shaping the 2024 Medicare Advantage landscape, directly impacting resident referral patterns and facility bottom…

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HHS-OIG’s Efforts Result in $7.13 Billion in Expected Recoveries and Receivables

December 4, 2024

America’s taxpayers could see recoupment of billions of dollars in misspent Medicare, Medicaid, and other health and human services funds as a result of work…

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Medicare Advantage Plans With High Numbers Of Veterans: Enrollment, Utilization, And Potential Wasteful Spending

November 2, 2024

Health Affairs

Medicare Advantage (MA) plans are increasingly enrolling veterans. Because MA plans receive full capitated payments regardless of whether or not veterans use Medicare services, the…

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Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care

October 24, 2024

US Senate

The Senate Homeland Security and Governmental Affairs Committee’s majority staff report on Medicare Advantage highlights three key takeaways regarding overpayments and manipulative practices: Medicare Advantage…

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Assessing Medicaid Payment Rates and Costs of Caring for the Medicaid Population Residing in Nursing Homes: Final Report

October 11, 2024

HHS ASPE

The purpose of this research was to understand the relationship between state Medicaid payment rates to nursing homes and those facilities’ costs of providing care…

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journal-of-post-acute-and-long-term-care-medicine

Trends in Post-Acute Care use in Medicare Advantage Versus Traditional Medicare: A Retrospective Cohort Analysis

October 1, 2024

JAMDA

Study ObjectivesWe sought to describe national trends in hospitalization and post-acute care utilization rates in skilled nursing facilities (SNFs) and home health (HH) for both…

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Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions

October 1, 2024

Medicare Advantage (MA) companies receive higher risk-adjusted payments from the Centers for Medicare & Medicaid Services (CMS) for enrollees who are sicker, which helps to…

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Dual-Eligible Nursing Home Residents: Enrollment Growth In Managed Care Plans That Coordinate Care, 2013–20

September 30, 2024

Health Affairs

“Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital…

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Medicare Advantage Quality Bonus Payments Will Total at Least $11.8 Billion in 2024

September 11, 2024

GAINING CLARITY: This must-read for skilled nursing facilities dissects key trends shaping the 2024 Medicare Advantage landscape, directly impacting resident referral patterns and facility bottom…

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Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022

August 8, 2024

GAINING CLARITI: This analysis from KFF highlights the substantial increase in prior authorization requests for Medicare Advantage beneficiaries, exceeding 46 million in 2022. This trend…

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Medicare Advantage in 2024: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization

August 8, 2024

In 2024, three quarters (75%) of enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premium other than the Medicare Part B…

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Structural Inequities in Medicare Advantage — A Growing Cause for Concern

July 23, 2024

JAMA

From its inception, Medicare Advantage (MA), a program in which private health insurers contract with the Medicare program to provide coverage on a capitated basis,…

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Unfulfilled Home Health Referrals Lead to Higher Mortality Among Medicare Advantage Members

July 9, 2024

American Journal of Managed Care

Key Takeaways Following acute hospitalization, Medicare Advantage members with orders to receive home health may not ultimately receive these services for member- and health care…

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Denials and Appeals in Medicaid Managed Care

March 30, 2024

MACPAC

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…

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Coverage Denials in Medicare Advantage—Balancing Access and Efficiency

March 1, 2024

JAMA

“Given the lack of available data to describe MA claim denials, increasing transparency is a critical first step. Although the rule requires public disclosure of…

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How Medicare Advantage is Shaping the Care of Older Adults with Serious Illness

December 21, 2023

Innovation in Aging

The Medicare Advantage (MA) program currently insures half of Medicare beneficiaries, and yet there are major gaps in our understanding of how it is impacting…

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Medicare Advantage: Growth Amidst Mounting Scrutiny

October 18, 2023

Journal of the American Board of Family Medicine

The Medicare Advantage Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. The Government Accountability Office called on…

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High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care

July 30, 2023

Three factors raise concerns that some people enrolled in Medicaid managed care may not be receiving all medically necessary health care services intended to be…

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Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients

April 30, 2023

Health Affairs

Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates…

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Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare: A Review of the Literature

September 16, 2022

The growing role of Medicare Advantage in the Medicare program and the changing demographics of Medicare Advantage enrollees have given rise to an interest in…

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Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care

April 27, 2022

GAINING CLARITY: This compilation of OIG resources focused on managed care provides a centralized hub for understanding the oversight and compliance landscape related to Medicare…

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CMS’ Medicare Benefit Policy Manual

October 5, 2023

The Medicare Benefit Policy Manual is published online by the U.S. Centers for Medicare & Medicaid Services, or CMS. Its used by health care providers, contractors, Medicare Advantage companies and…

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Expanding Medicare Advantage co-pays may leave nursing homes without cash they’ve earned

December 9, 2024

McKnights

An increasing number of Medicare Advantage insurers are expected to institute nursing home co-pays starting Jan. 1, a change that could further hit providers already struggling to collect fair reimbursement…

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Medicare Spending was 27% More for People who Disenrolled from Medicare Advantage than for Similar People in Traditional Medicare

December 6, 2024

GAINING CLARITY: This must-read for skilled nursing facilities dissects key trends shaping the 2024 Medicare Advantage landscape, directly impacting resident referral patterns and facility bottom lines.

Read this article

HHS-OIG’s Efforts Result in $7.13 Billion in Expected Recoveries and Receivables

December 4, 2024

America’s taxpayers could see recoupment of billions of dollars in misspent Medicare, Medicaid, and other health and human services funds as a result of work by the Department of Health…

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Best Practices for Medicare Advantage Case Management and Appeals

December 1, 2024

Clariti

GAINING CLARITY: This Clarity Guide details case management strategies for post acute providers to improve their work with managed care payers.

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Negotiating to Win at Managed Care Contract Negotiations

December 1, 2024

Clariti

GAINING CLARITY: This Clarity Guide offers best practices for post-acute providers working on agreements with Medicare Advantage payers.

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A Guide to Medicare Advantage and Managed Care Contracting for Post Acute Providers

December 1, 2024

Clariti

GAINING CLARITY: This Clarity Guide details the unique features and considerations for post acute providers working with Medicare Advantage payers.

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Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program

November 26, 2024

On November 26, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would revise the Medicare Advantage (MA) Program, Medicare Prescription Drug Benefit Program (Part…

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Medicare Advantage Proves To Be the ‘Most Profound’ Disruptor for Nursing Homes, Reshaping Payer Dynamics

November 18, 2024

Skilled Nursing News

Of the many significant factors affecting the skilled nursing industry in the last five years, Medicare Advantage was named as a major disruptor, as cost reports show a shift in…

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Medicare Advantage 2025 Spotlight: A First Look at Plan Offerings

November 15, 2024

Over the last decade, Medicare Advantage, the private plan alternative to traditional Medicare, has taken on a prominent role in the Medicare program. In 2024, nearly 33 million Medicare beneficiaries are enrolled…

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How to Survive Medicare Advantage in Home Health

November 15, 2024

Rowan Report

Navigating the complexities of Medicare Advantage continues to be a sticking point for organizations trying to scale their business. In an education session at the 2024 Axxess Growth, Innovation and Leadership Experience…

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What the Outcome of the Election Could Mean for Medicaid

November 14, 2024

On the campaign trail, both former President Donald Trump and Vice President Kamala Harris are eager to portray themselves as guardians of Medicare. Each presidential candidate accuses the other of…

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The Sickest Patients Are Fleeing Private Medicare Plans—Costing Taxpayers Billions

November 11, 2024

Wall Street Journal

Patricia Greene had spent a month recovering from a devastating stroke when her Medicare Advantage insurer, a unit of UnitedHealth Group, decided to stop paying for her nursing home. The…

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Nursing Home Providers Adjust to Optum Exiting Medicare Advantage I-SNPs in Several Regions

November 5, 2024

Skilled Nursing News

Optum is scaling back its Medicare Advantage Special Needs Plans for nursing home and assisted living residents in several regions. The health care services arm of insurance giant UnitedHealth Group…

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It’s UnitedHealth Group’s world — we just live in it

November 4, 2024

McKnights

…On Oct. 24 a report from the US Department of Health and Human Services Office of the Inspector General was published that was just the latest evidence of how MA insurers pilfer…

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Medicare Advantage Plans With High Numbers Of Veterans: Enrollment, Utilization, And Potential Wasteful Spending

November 2, 2024

Health Affairs

Medicare Advantage (MA) plans are increasingly enrolling veterans. Because MA plans receive full capitated payments regardless of whether or not veterans use Medicare services, the federal government can incur substantial…

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Denied but in denial no longer: Providers share successful Medicare Advantage strategies

October 31, 2024

McKnights

Document. Don’t delay. Designate a handler. Those were among top tips provided by managed care and skilled nursing experts who have fine-tuned their approach to getting resident care approved by…

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UnitedHealth Study: Is Medicare Advantage Killing Seniors

October 25, 2024

Rowan Report

Dr. Steve Landers has long been eloquent in his speaking and writing about the importance of Home Health over the years. Though I was already impressed, I gained a new…

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Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care

October 24, 2024

US Senate

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“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

October 23, 2024

ProPublica

Every day, patients across America crack open envelopes with bad news. Yet another health insurer has decided not to pay for a treatment that their doctor has recommended. Sometimes it’s…

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Transition to Managed Medicaid Causing Chain Reaction of Challenges, as Nursing Homes Also Contend With Redetermination

October 15, 2024

Skilled Nursing News

Multiple states have been working toward a transition to managed Medicaid from the traditional state-run program, but there have been concerns about reimbursement timing and insufficient payment amounts due to…

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