HJBR Sep/Oct 2024

HEALTHCARE JOURNAL OF BATON ROUGE I  SEP / OCT 2024 11 between IRFs and nursing homes for 2018. 6 OIG has also warned that MA plans may deny needed care “in an attempt to increase their profits,”misusing funds that CMS paid for people’s healthcare. 7 In 2022, OIG physi- cians audited MA care denials for IRF ser- vices and found that in some cases patients met admission criteria, needed higher-level care, and alternatives were insufficient to meet their needs. 6 Studies have found that MA enrollees “are more likely to enter lower-quality nursing homes compared to fee-for-service enrollees.” 8 When used appropriately, prior autho- rization can limit low-value services, but healthcare providers also caution that “cost containment provisions that do not have proper medical justification can put patient outcomes in jeopardy.” 9 A recent Kaiser Family Foundation (KFF) study comparing MAplans found that “prior authorization requests were most com- mon for Humana plans.” 10 Humana did not respond to requests for comments on its prior authorization practices under new federal rules. This year, CMS warned MA plans may not deny a hospital patient’s request for discharge to an IRF or redirect care to a different setting if a physician orders these services and the patient qualifies under Medicare coverage rules. 11 Yet, plans have significant leeway in how they interpret this directive, and families often lack the time to appeal when the patient is ready to leave the hospital. Fickle said her father needed intensive therapy at Northshore Rehabilitation Hos- pital in Lacombe, Louisiana. Speaking of the value of IRF care, the hospital’s CEO Laurel Dupont said, “One single hospital readmis- sion would cost [MA plans] as much as, if not more than, the entire rehab stay. North- shore Rehab had zero readmissions of an amputee patient during all of 2023.”Astudy by Dobson DaVanzo & Associates compar- ing IRF and skilled nursing facility patients found that IRF patients returned home ear- lier and remained there longer, with lower mortality rates, emergency room visits, and hospital readmissions. 12 Several providers report concerning automatic denials for IRF services. In recent months, TIRR Memorial Hermann Health System in Houston reported receiving auto- matic MA denials for 90% of prior autho- rization requests. “If they give us a denial, they’ll say you can go to [a peer-to-peer call with our physician] or you can go ahead and discharge to a nursing home, and I’ll give you that approval now,”said financial clear- ance manager Courtney Roberson, adding that these automatic denials often keep a patient in the hospital for four to five days longer, taking weekends into account. Patients also stay in the hospital lon- ger because MA plans are not required to include IRFs in their provider networks, even though IRF services are a Medicare- covered benefit. “It’s not right for Medicare beneficiaries to not have access to this level of care,”said TIRRMemorial Hermann CEO Rhonda M. Abbott. “It doesn’t make sense to eliminate a whole level of care.” Last year during a congressional hearing, the American Hospital Association (AHA) described howMAplans financially benefit from these post-acute care delays, explain- ing that “the plan has already paid the hos- pital a flat rate for care and is either delay- ing or attempting to avoid discharging the patient to the next site of care, which would require a separate, additional reimburse- ment. AHA claims data analysis reflects that length of stay in the referring hospital is typically longer for MAbeneficiaries than traditional Medicare beneficiaries being “Several providers report concerning automatic denials for IRF services. In recent months, TIRR Memorial Hermann Health System in Houston reported receiving automatic MA denials for 90% of prior authorization requests.”