CMS Proposal Marks Shift After Years of Skilled Nursing Frustration with Medicare Advantage Diversions

The Centers for Medicare & Medicaid Services (CMS) has decided to take action on transitions in care – specifically Medicare Advantage (MA) plans diverting care to home health instead of skilled nursing – after years of skilled nursing industry and consumer feedback.

CMS last month took steps to address the trend with a proposed rule focused on providing choice when it comes to post-acute and long-term care placement. In the rule, CMS said MA organizations (MAOs) can’t apply coverage criteria that is more restrictive than traditional Medicare coverage.

“CMS is responding to two things. One is feedback that they have heard from the industry for many years,” Fred Bentley, managing director at ATI Advisory, told Skilled Nursing News. “There’s also a report that came out in April of last year … it touched on concerns around access to skilled nursing care, and potential issues around substituting home health for skilled nursing care.”

Bentley refers to a Health and Human Services Office of the Inspector General (OIG) report published April 27, which found that among prior authorization requests MAOs denied, 13% met Medicare coverage rules. They likely would have been approved for these beneficiaries under traditional Medicare, according to the report.

Coupled with SNF complaints and the OIG report, there’s also a recognition that post-acute care hasn’t been a large part of conversations surrounding the MA program, he said. CMS has instead focused on making hospitals and physicians define network adequacy.

It’s a “somewhat belated” acknowledgement that post-acute care is a crucial aspect of MA beneficiaries’ access to care, Bentley told SNN.

MA diversion a years-long trend

Crystal Bene, director of inpatient case management at Sentara Norfolk General Hospital, said she and her colleagues are seeing a “broad tendency” among MA plans to deny SNF and long-term acute care hospital (LTACH) placements in favor of home care nursing and rehabilitation.

Sentara Healthcare, parent company for the Norfolk hospitals, also offers health plans – including MA plans – through its subsidiaries Optima Health and Virginia Premier. 

“SNF denials add to hospital length of stay and can jeopardize post-acute recovery when patients are unable to safely navigate their homes,” Bene said in a statement. “We are also seeing that patient families who appeal SNF denials often succeed in reversing them, when details of a patient’s condition and caregiver support are clear.”

J. Mark Traylor, president of Traylor-Porter Healthcare in Alabama, said there have been instances where an MA beneficiary is sent to the nursing home from the hospital, only to have the MA plan call to say the patient can only stay in the facility for three days.

Traylor, who also serves on the board of health plan Simpra Advantage, calls it a “numbers game,” with providers often caught in the middle.

“We are working with health plans to rectify this tendency to deny and we believe the CMS ruling will encourage patient safety and better outcomes,” Bene said.

Heidi Wold, chief clinical officer for Longevity Health Plans, says she understands why this trend may be concerning for CMS, with aggressive work being done to divert people to home instead of SNFs even before the pandemic.

As a former health care quality improvement director for the Florida Medicare Quality Improvement Organization (QIO) between 2000 and 2002, Wold saw a similar but lesser degree of grievances related to beneficiaries being sent home without needed support; she worked with beneficiaries and the grievance team to determine a root cause of the grievances for CMS.

“We had several grievances from people being pushed into home health, versus being able to continue their stay in the nursing home, or being able to go to skilled nursing,” said Wold.

Coupled with the simple diversion to a different care setting, Bentley agreed with Traylor that other frustrations that get “wrapped up” in SNF feedback involve length of stay for MA beneficiaries, and reimbursement generally being lower compared to Medicare fee-for-service, or traditional Medicare.

“Outsourced post-acute managers are really clamping down on length of stay and shipping them out of facilities earlier than [SNFs] think is appropriate, and they’re not paying as much … that all plays into this,” added Bentley.

Who should make the call

Leaders in the industry agree a patient’s physicians should be at the heart – or at least the start – of determining the right placement for patients.

Wold agreed that providing options and member choice are the best ways for managed care plans to work through discharge discrepancies. Ultimately, the decision should be made by the patient’s treating physician, provider working with the beneficiary, or their legal authorized representative.

“I think where the gray area comes in is, where do Medicare Advantage plans fit in? Do they have a say in this? If so, how much of a say?” said Bentley. “CMS spelled out in the proposed rule that yes, MA plans can and should have a say in this, but they need to base those decisions on compelling clinical evidence from the research.”

Jonathan Gold, senior associate director of payment policy for the American Hospital Association (AHA), said in an email that care settings should be determined by providers, in consultation with the patient.

Under federal Medicare criteria, MA plans don’t have the discretion to impose their own criteria beyond what is in regulation, he added. Patient access to medically necessary, covered services shouldn’t be delayed or impeded as a result of certain health plan policies.

“Providers across the post-acute care continuum have reported that the prior authorization process employed by MA plans impedes their ability to provide the best care and outcomes for patients,” Gold wrote. “When MA plans use inappropriate criterion, it adds to provider burden as they work to justify admissions and appeal determinations. It also delays initiation of care such as physical or occupational therapy, and patients arrive more debilitated than would otherwise be the case.”

AHA has been outspoken on this issue in the past, releasing a statement when CMS first announced the proposed rule last month.

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) kept a more neutral stance, asserting that the decision should be centered around the patient and their goals. “Full collaboration” between the insurers, caregivers and doctors should work toward these ends, the association said in an email to Skilled Nursing News.

If there is a disagreement with the proposed discharge plan option communicated by a health plan, the beneficiary’s treating physician can request a discussion with the health plan’s physician in what Wold calls a peer-to-peer meeting. The patient’s doctor and health plan doctor have a direct conversation about transitions in care and best options based on the member’s need.

The next step would involve the beneficiary or their responsible party filing a grievance with the health plan, saying they did not agree with the decision, Wold explained. This grievance would be reviewed and could be sent to an external organization for final determination.

Hospital-at-Home and Hospital-to-Home programs have worked to allow people to bypass the skilled nursing setting and go directly home, Wold said – still with constant monitoring and intensive care services.

“People getting choices on which one they choose to do, based on what their medical needs and other needs are, is really at the root of this, I believe. It is a trend,” said Wold. “There are several different companies out there that are working on or have done these transition-to-home programs.”

Contessa and Dispatch Health come to mind when discussing Hospital-at-Home, but many other companies offer the Hospital-to-Home program, she said.

“Could everybody do a better job of communicating and giving members some choices? Probably,” said Wold.

Health plans should be laying out options for the beneficiary instead of mandating where they should go, she said – in other words, more power should be placed in the hands of the patient and their treating physician with guidance from the health plan on which covered benefits would apply for member care transitions.

A data fork in the road, so to speak, comes from algorithms used by managed care plans and providers that take into account patient demographics and functional status, among other data points, to determine where a patient should go for post-acute care.

“It takes the choice out for the member,” said Wold. “The member will be assigned their post discharge care option to whatever the algorithm demonstrates is the ‘right’ option for them. These types of beneficiary experiences as well as other trends have led to this frustration.”

By contrast, Bentley says data from such companies makes care transition decisions “abundantly clear” while physician opinions could vary by geography, across different hospitals and health systems or on an individual basis with physicians in the very same building.

Dr. Lissy Hu, president of Connected Networks at care coordination software company CarePort, powered by WellSky, said such data analytics help substantiate claims for a certain care setting without taking precious time away from clinicians.

“There’s a lot of back and forth involved in this process, and especially given some of their staffing challenges, [hospitals and nursing homes] want their nurses to be doing clinical work, rather than taking care of clerical work, faxing documentation,” said Hu.

Data companies like WellSky can connect providers to health plan delegates, facilitating many of the post-acute authorization pieces, she said.

“There is that unwarranted variation; that’s just a reality,” added Bentley. “I think at the end of the day, [transitions in care] still need to be based on those individuals, those clinicians, those physicians who have been treating the patient that know their condition.”

By what criteria?

More weight should be placed on physician decisions, Traylor said, compared to all the other voices vying to be heard – MA plans, nursing home operators, hospitals, residents and their families among them.

“You’ve got to let the people on the battlefield make the decisions about what needs to be done. I think doctors are trained to do that,” said Traylor.

Traylor’s own mother serves as a prime example – after knee surgery, she decided to go home instead of receiving therapy at a nursing home. His mother saved Medicare a lot of money by choosing to go home, Traylor said, but she did not benefit and still walks with a limp.

The lower the patient’s acuity and socioeconomic conditions, he added, the more judgmental parties are on where to send beneficiaries for post-acute care.

Traylor-Porter doesn’t get a lot of elective hip and knee replacement surgery recovery cases, but when they do, there’s sometimes disagreement with MA plans – especially if the patient is more frail.

MA plans usually want to send these patients home, he said, although the patient and family may not be ready. Operators are fighting to keep these patients while MA plans are trying to discharge them every three to five days.

“They hold the purse strings, so they win,” added Traylor.

National and local coverage determination and health plan policies need to be followed while also considering the physical, medical and other needs of the beneficiary and their ability to care for themselves, Wold noted.

In a best case scenario, the patient’s needs are well articulated by the hospital, she added – the more complete the documentation is of the patient’s physical, psychosocial, emotional and skilled nursing needs, the better chance for appropriate placement.

And ACHA/NCAL stressed that older adults also have changing needs, and so the evaluation of the most appropriate setting and the accessibility of care must take this into account. As the organization put it in its emailed statement:

“It is critically important that seniors have access to every option so their needs can be met in the right care setting, especially as those needs evolve.”