[CoachKandSportsguy]

Reforming Prior Authorizations

Copy if link doesn't work
So don't complain about cheap if you get stuck or subpar care
---------------------------------------------------------------

In April There Were 1,972 Patients Stuck in Mass. Hospitals

The latest MHA throughout report shows that in April there were 1,972 patients stuck in Massachusetts hospital beds awaiting transfer to the next level of care at a rehabilitation facility or home care.

The number jumped from the previous month’s total of 1,500 patients, due partly to rising patient volumes across the system but also because of new reporting from two large academic medical centers. While the new reporting was added to the report, it is important to note that the nearly 2,000 stuck patient figure is from just 38 of approximately 64 reporting hospitals in the state.

The inability of a patient to transfer to the next level of care affects not only the health and recovery of the patient, but also hospital finances and worker wellbeing (see next story).

The instability of the Steward Health Care system is contributing to the problem, as are other facility closures in recent years, including the increase in nursing home closures across Massachusetts. Even if beds were increased through pandemic-era flexibilities, it's unclear if there would be enough healthcare workers to staff them.

“Among other tools, we need Massachusetts to join the Nurse Licensure Compact (NLC) so we can simplify the licensure process for RNs to come and work in our state. And we need prior authorization reform so we can cut through the needless red tape hampering patient transfers,” said MHA’s Senior Vice President of Government Advocacy and General Counsel Mike Sroczynski. “We need meaningful healthcare legislation that reflects the realities and voices of today’s healthcare system. All of these things are within reach before the legislative session ends.”

Hospital Case Managers: Insurer Prior Authorizations a Problem
As the Massachusetts healthcare system reels from having nearly 2,000 patients stuck in Massachusetts hospitals and unable to transition to the next level of needed care (see above story), the collective focus of policymakers and the healthcare community is on how to resolve the problem.

Last week, MHA sat down with three case managers from a large hospital system to discuss the common problems they face once a patient has been assessed for discharge to some form of rehabilitative care. The case managers are clinical professionals who work with other clinicians – occupational and physical therapists, speech pathologists, and physicians, among others – as well as with skilled nursing facilities, health insurance companies, patients, and their families to orchestrate care transitions for patients. And the case managers all agree that the major problem with the process – the sand in the gears of care transitions – is the health insurance company prior authorization process, especially those from Medicare Advantage insurers.

MHA has filed legislation jointly with the Massachusetts Medical Society and Health Care For All that would address some of the difficulties patients and providers encounter from commercial health insurance companies’ prior authorization policies. The legislation would not eliminate prior auth and still allow insurers to use it as a means of controlling costs; but under the MHA-MMS-HCFA proposal, low-value prior authorization requirements would be eliminated and the process streamlined.

According to an MHA report, Massachusetts can remove as much as $1.75 billion in wasted costs through “sensible” insurance-related reforms – particularly through simplifying prior auth processes.

Delays of 5-to-10 Days

“Take, for example, the very common example of a patient who on Thursday gets assessed by the physical therapist, who recommends short-term rehab for the patient,” says one case manager. (The managers requested anonymity to avoid any further friction with the insurers with which they deal.) “One of our case managers talks to the patient’s family on Thursday and makes the referral for rehab, anticipating that the patient will be ready the next day.”

The first difficulty encountered is finding an open bed at a skilled nursing facility (SNF). But if a bed is found, the SNF will request authorization from the insurer for the transfer.

“And then we’re in a holding pattern,” the case manager says. “It takes two-to-three days for a prior authorization. And while we’re a seven-days-a-week operation, the insurers, especially the national Medicare Advantage plans, don’t work on the weekends. So now we’re into the following Tuesday to move a patient who we identified on the previous Thursday was ready to be transferred.”

The system case manager did note that interacting with Massachusetts-based insurers is generally easier than dealing with the national Medicare Advantage plans: “We can often get on the phone with a local insurer and say, ‘Please, can you move this patient to the top of the list.’”

Denials Extend the Process

A five-day transfer delay is troubling, but more disturbing is an insurer’s arbitrary denial of an authorization request, which will extend the transfer delay even longer.

“Often an insurer will say, for instance, that a patient can be managed at home even though we’ve conducted an assessment indicating that rehab is necessary,” one case manager says. “So we have to appeal it, supplying additional clinical information, or sometimes there is a peer-to-peer call between our physician and the insurer’s clinician. That means a hospital physician, who is supposed to be caring for patients, has to take time to coordinate a phone call, which often can be a laborious process to nail down a time, and often results on them being put on hold as they wait to talk to somebody.”

Appealing a denial can take days. And once the weekend comes, the process is shut down until the insurer’s utilization teams return to work on Monday morning. That means a patient can be stuck in a hospital bed for 10 days or more.

The Effect on Patients

When a patient is stuck in a hospital after being cleared for discharge, problems mount. Insurance companies typically pay hospitals a fixed amount per-patient, per-diagnosis. If a patient is stuck in a hospital for additional days after their course of care has been completed, the hospital generally does not receive any additional funding and often must absorb the additional costs on its own – to the tune of more than $400 million each year across all Massachusetts hospitals. Plus the occupied bed cannot be used to help ease overcrowding on a hospital’s emergency department.

But the main harm from the stalled prior authorization process is to the patient.

“Hospitals are not set up to provide multi-hour rehabilitation therapy to patients, so they’re deconditioning while they are waiting, which means it takes even longer for their recovery process once they do get into a rehab,” according to the case manager. And the longer a patient is forced to stay in a hospital, the greater chance he or she has of contracting a nosocomial infection.

Patients stuck in a hospital, aware of the prior authorization problem, may naturally try to contact their insurer themselves, according to the case manager. This generates another common problem since the 800-number on the back of an insurance card directs a patient to the insurer’s member relations department. Member relations will tell the patient the basics of their plan—namely, “Of course, you have the right to rehabilitation care.” Unfortunately, the utilization review department of the insurer is the one making the authorization denial – and the two departments rarely talk.

“So the patient loses trust in us, the people caring for them, because they do not believe what we are saying,” the case manager says. “It puts strain on the relationship between the hospital and the patient, it puts strain on the patient because they have to stay in the hospital, and it puts strain on us because we’re trying desperately to do right by patients.”

Solutions to the Problem

The case managers said much of the problem could be erased by two main actions. First, expanding an insurance company’s network of post-acute providers would allow a hospital to find a bed across the state that a patient’s insurer covers, thereby removing the fear of the patient paying out-of-network penalties or paying for their care entirely out-of-pocket.

But more importantly is the standardization of how to submit prior authorizations to the various insurers, and how quickly they are required to respond. Beginning in January 2026, under new federal guidelines, the timeframes for Medicare Advantage insurers to respond to prior authorization requests from providers will be reduced from 14 calendar days to 7 calendar days for standard requests while expedited requests remain at 72 hours. MHA recently wrote to the Centers for Medicare & Medicaid Services saying that even a 72-hour turnaround is too long – and the case managers agree.

But how about the argument that the insurers, although sometimes delayed in their responses, serve the important purpose of keeping costs in check?

“Prior authorization themselves are not the problem; it’s the processes associated with them," said one case manager from the interviewed hospital. "The insurance company is not physically at the bedside assessing the patient, so they have to rely on our clinical professionals. The insurers require a physical therapy evaluation, an assessment, and we provide that to them when we make a transfer request. We are physically with the patient doing that assessment; the insurance company isn’t. We can see that the patient is not able to ambulate and cannot safely go home; the insurance company can’t."

The case manager noted that if the patient didn’t have a Medicare Advantage insurer and had traditional Medicare instead, the transfer likely would be approved.

"Medicare Advantage insurers are required by law to provide the same if not more services than traditional Medicare, but they often do not," the case manager said. "And they’re doing a disservice to their patients by restricting them and causing long delays in getting to the next site of care.”

Enhancing Hospital-to-Home to Ease Capacity Crunch
While attempts to resolve the insurer prior authorization problem continues, the Healey Administration last week took another path to ease the capacity crisis: using American Rescue Plan Act Home and Community-Based Services funding to award $1.1 million to hospital and Aging Services Access Points (ASAPs) to expand the Hospital-to-Home Partnership Program.

The program helps discharge patients to their homes rather than to skilled nursing facilities or other post-acute settings. Determining the best location for a patient's post-acute-hospital care is still left to the discretion of the patient's care team.

There are currently 24 ASAPs across the state that help those over age 60 with care options, nutrition, food security, housing, financial wellness, transportation, and safety.

[Stu from NYC]

HMO's can have the same problem taking too long to send info to Insurance companies

[tophcfa]

But advantage plans are cheap or no cost, compared to supplemental plans, and offer to pay for a health club membership? News flash, there is no free lunch out there! Advantage plans are a better value, right up to the point where you need them. It’s very scary to think that there is a push by some to move all of Medicare to private insurers.

[Stu from NYC]

Originally Posted by tophcfa

But advantage plans are cheap or no cost, compared to supplemental plans, and offer to pay for a health club membership? News flash, there is no free lunch out there! Advantage plans are a better value, right up to the point where you need them. It’s very scary to think that there is a push by some to move all of Medicare to private insurers.

Overall it has worked out very well for us but there have been a few hiccups.

[justjim]

People are living longer and the “medical community”
Is operating on a critical shortage of workers. That said, private company advantage plans come in all shapes and forms but the insurance companies are making lots of money or they wouldn’t insure Medicare eligible individuals. Look at their “balance sheets.” Capitalism at its best and that is what we are all about.

[OrangeBlossomBaby]

Aren't there some Medicare Advantage plans that don't require referrals as long as the destination is in-network? I thought United Healthcare and Anthem both had these plans in addition to the usual referral-required ones.

[Badger 2006]

Originally Posted by OrangeBlossomBaby

Aren't there some Medicare Advantage plans that don't require referrals as long as the destination is in-network? I thought United Healthcare and Anthem both had these plans in addition to the usual referral-required ones.

I have Florida Blue Advantage PPO and referrals are not needed for In-Network (Less expensive) or Out-of-Network (More expensive). There can be significant differences between HMO and PPO Advantage Plans.

[Carla B]

I first heard of Medicare Advantage programs back in the 1980's. Someone I casually worked for explained to me that he had recently enrolled in senior healthcare through Humana.

The way it worked, he explained, was that Social Security transferred his monthly Medicare premium to Humana in exchange for covering his healthcare needs, even prescriptions and eyeglasses, and what a great deal that was. At that time I was too young to worry about such concerns. But it did make a huge impression on me when he told me a few months later that the Humana program had gone insolvent and he was back to searching for doctors.

From then on, I took notice of company after company advertising their Advantage program and going out of business not long after.
When we reached the time where we had to make a choice, I voted in favor of paying for Medigap as long as possible, even if we had to give up such niceties as eating out a couple times a week. My husband agreed, since he had a history of unusual health concerns and preferred choosing his own doctors.

So, here we are some years later, mostly eating at home but still able to pay Medigap premiums, even though insurance companies have figured out how they can profit from Advantage programs.

[tophcfa]

Originally Posted by CoachKandSportsguy

Reforming Prior Authorizations

Copy if link doesn't work
So don't complain about cheap if you get stuck or subpar care
---------------------------------------------------------------

In April There Were 1,972 Patients Stuck in Mass. Hospitals

The latest MHA throughout report shows that in April there were 1,972 patients stuck in Massachusetts hospital beds awaiting transfer to the next level of care at a rehabilitation facility or home care.

The number jumped from the previous month’s total of 1,500 patients, due partly to rising patient volumes across the system but also because of new reporting from two large academic medical centers. While the new reporting was added to the report, it is important to note that the nearly 2,000 stuck patient figure is from just 38 of approximately 64 reporting hospitals in the state.

The inability of a patient to transfer to the next level of care affects not only the health and recovery of the patient, but also hospital finances and worker wellbeing (see next story).

The instability of the Steward Health Care system is contributing to the problem, as are other facility closures in recent years, including the increase in nursing home closures across Massachusetts. Even if beds were increased through pandemic-era flexibilities, it's unclear if there would be enough healthcare workers to staff them.

“Among other tools, we need Massachusetts to join the Nurse Licensure Compact (NLC) so we can simplify the licensure process for RNs to come and work in our state. And we need prior authorization reform so we can cut through the needless red tape hampering patient transfers,” said MHA’s Senior Vice President of Government Advocacy and General Counsel Mike Sroczynski. “We need meaningful healthcare legislation that reflects the realities and voices of today’s healthcare system. All of these things are within reach before the legislative session ends.”

Hospital Case Managers: Insurer Prior Authorizations a Problem
As the Massachusetts healthcare system reels from having nearly 2,000 patients stuck in Massachusetts hospitals and unable to transition to the next level of needed care (see above story), the collective focus of policymakers and the healthcare community is on how to resolve the problem.

Last week, MHA sat down with three case managers from a large hospital system to discuss the common problems they face once a patient has been assessed for discharge to some form of rehabilitative care. The case managers are clinical professionals who work with other clinicians – occupational and physical therapists, speech pathologists, and physicians, among others – as well as with skilled nursing facilities, health insurance companies, patients, and their families to orchestrate care transitions for patients. And the case managers all agree that the major problem with the process – the sand in the gears of care transitions – is the health insurance company prior authorization process, especially those from Medicare Advantage insurers.

MHA has filed legislation jointly with the Massachusetts Medical Society and Health Care For All that would address some of the difficulties patients and providers encounter from commercial health insurance companies’ prior authorization policies. The legislation would not eliminate prior auth and still allow insurers to use it as a means of controlling costs; but under the MHA-MMS-HCFA proposal, low-value prior authorization requirements would be eliminated and the process streamlined.

According to an MHA report, Massachusetts can remove as much as $1.75 billion in wasted costs through “sensible” insurance-related reforms – particularly through simplifying prior auth processes.

Delays of 5-to-10 Days

“Take, for example, the very common example of a patient who on Thursday gets assessed by the physical therapist, who recommends short-term rehab for the patient,” says one case manager. (The managers requested anonymity to avoid any further friction with the insurers with which they deal.) “One of our case managers talks to the patient’s family on Thursday and makes the referral for rehab, anticipating that the patient will be ready the next day.”

The first difficulty encountered is finding an open bed at a skilled nursing facility (SNF). But if a bed is found, the SNF will request authorization from the insurer for the transfer.

“And then we’re in a holding pattern,” the case manager says. “It takes two-to-three days for a prior authorization. And while we’re a seven-days-a-week operation, the insurers, especially the national Medicare Advantage plans, don’t work on the weekends. So now we’re into the following Tuesday to move a patient who we identified on the previous Thursday was ready to be transferred.”

The system case manager did note that interacting with Massachusetts-based insurers is generally easier than dealing with the national Medicare Advantage plans: “We can often get on the phone with a local insurer and say, ‘Please, can you move this patient to the top of the list.’”

Denials Extend the Process

A five-day transfer delay is troubling, but more disturbing is an insurer’s arbitrary denial of an authorization request, which will extend the transfer delay even longer.

“Often an insurer will say, for instance, that a patient can be managed at home even though we’ve conducted an assessment indicating that rehab is necessary,” one case manager says. “So we have to appeal it, supplying additional clinical information, or sometimes there is a peer-to-peer call between our physician and the insurer’s clinician. That means a hospital physician, who is supposed to be caring for patients, has to take time to coordinate a phone call, which often can be a laborious process to nail down a time, and often results on them being put on hold as they wait to talk to somebody.”

Appealing a denial can take days. And once the weekend comes, the process is shut down until the insurer’s utilization teams return to work on Monday morning. That means a patient can be stuck in a hospital bed for 10 days or more.

The Effect on Patients

When a patient is stuck in a hospital after being cleared for discharge, problems mount. Insurance companies typically pay hospitals a fixed amount per-patient, per-diagnosis. If a patient is stuck in a hospital for additional days after their course of care has been completed, the hospital generally does not receive any additional funding and often must absorb the additional costs on its own – to the tune of more than $400 million each year across all Massachusetts hospitals. Plus the occupied bed cannot be used to help ease overcrowding on a hospital’s emergency department.

But the main harm from the stalled prior authorization process is to the patient.

“Hospitals are not set up to provide multi-hour rehabilitation therapy to patients, so they’re deconditioning while they are waiting, which means it takes even longer for their recovery process once they do get into a rehab,” according to the case manager. And the longer a patient is forced to stay in a hospital, the greater chance he or she has of contracting a nosocomial infection.

Patients stuck in a hospital, aware of the prior authorization problem, may naturally try to contact their insurer themselves, according to the case manager. This generates another common problem since the 800-number on the back of an insurance card directs a patient to the insurer’s member relations department. Member relations will tell the patient the basics of their plan—namely, “Of course, you have the right to rehabilitation care.” Unfortunately, the utilization review department of the insurer is the one making the authorization denial – and the two departments rarely talk.

“So the patient loses trust in us, the people caring for them, because they do not believe what we are saying,” the case manager says. “It puts strain on the relationship between the hospital and the patient, it puts strain on the patient because they have to stay in the hospital, and it puts strain on us because we’re trying desperately to do right by patients.”

Solutions to the Problem

The case managers said much of the problem could be erased by two main actions. First, expanding an insurance company’s network of post-acute providers would allow a hospital to find a bed across the state that a patient’s insurer covers, thereby removing the fear of the patient paying out-of-network penalties or paying for their care entirely out-of-pocket.

But more importantly is the standardization of how to submit prior authorizations to the various insurers, and how quickly they are required to respond. Beginning in January 2026, under new federal guidelines, the timeframes for Medicare Advantage insurers to respond to prior authorization requests from providers will be reduced from 14 calendar days to 7 calendar days for standard requests while expedited requests remain at 72 hours. MHA recently wrote to the Centers for Medicare & Medicaid Services saying that even a 72-hour turnaround is too long – and the case managers agree.

But how about the argument that the insurers, although sometimes delayed in their responses, serve the important purpose of keeping costs in check?

“Prior authorization themselves are not the problem; it’s the processes associated with them," said one case manager from the interviewed hospital. "The insurance company is not physically at the bedside assessing the patient, so they have to rely on our clinical professionals. The insurers require a physical therapy evaluation, an assessment, and we provide that to them when we make a transfer request. We are physically with the patient doing that assessment; the insurance company isn’t. We can see that the patient is not able to ambulate and cannot safely go home; the insurance company can’t."

The case manager noted that if the patient didn’t have a Medicare Advantage insurer and had traditional Medicare instead, the transfer likely would be approved.

"Medicare Advantage insurers are required by law to provide the same if not more services than traditional Medicare, but they often do not," the case manager said. "And they’re doing a disservice to their patients by restricting them and causing long delays in getting to the next site of care.”

Enhancing Hospital-to-Home to Ease Capacity Crunch
While attempts to resolve the insurer prior authorization problem continues, the Healey Administration last week took another path to ease the capacity crisis: using American Rescue Plan Act Home and Community-Based Services funding to award $1.1 million to hospital and Aging Services Access Points (ASAPs) to expand the Hospital-to-Home Partnership Program.

The program helps discharge patients to their homes rather than to skilled nursing facilities or other post-acute settings. Determining the best location for a patient's post-acute-hospital care is still left to the discretion of the patient's care team.

There are currently 24 ASAPs across the state that help those over age 60 with care options, nutrition, food security, housing, financial wellness, transportation, and safety.

The saddest part about the above outlined situation is the collateral damage it causes to other patients in need of medical care. Patients sometimes can’t get out of an ER, and into a room desperately needed for care, because the rooms are occupied by patients whose insurers won’t approve the transfer to a rehabilitation facility.

[Stu from NYC]

Originally Posted by Carla B

I first heard of Medicare Advantage programs back in the 1980's. Someone I casually worked for explained to me that he had recently enrolled in senior healthcare through Humana.

The way it worked, he explained, was that Social Security transferred his monthly Medicare premium to Humana in exchange for covering his healthcare needs, even prescriptions and eyeglasses, and what a great deal that was. At that time I was too young to worry about such concerns. But it did make a huge impression on me when he told me a few months later that the Humana program had gone insolvent and he was back to searching for doctors.

From then on, I took notice of company after company advertising their Advantage program and going out of business not long after.
When we reached the time where we had to make a choice, I voted in favor of paying for Medigap as long as possible, even if we had to give up such niceties as eating out a couple times a week. My husband agreed, since he had a history of unusual health concerns and preferred choosing his own doctors.

So, here we are some years later, mostly eating at home but still able to pay Medigap premiums, even though insurance companies have figured out how they can profit from Advantage programs.

Cannot speak about other companies but Humana has seemed to figure it out

[CoachKandSportsguy]

Originally Posted by tophcfa

The saddest part about the above outlined situation is the collateral damage it causes to other patients in need of medical care. Patients sometimes can’t get out of an ER, and into a room desperately needed for care, because the rooms are occupied by patients whose insurers won’t approve the transfer to a rehabilitation facility.

There are financial losses as well when the patient can't leave and the insurance won't pay beyond a certain time, or the hospitals annual CMSs reimbursement metrics gets hosed.

[ithos]

It is only going to get worse.

To the casual observer in The Villages, it is apparent that many retirees do not put a high priority on proper diet and exercise. So when their health starts to deteriorate they figure it is now the government's job to shell out whatever money is required to pay for their medical expenses.

This wouldn't have been a problem in the 60s and 70s when medical care was far less advanced. But obviously things are much different now. Yes you paid Medicare taxes but it wasn't near enough.

Social Security and Medicare will run out of money in just over a decade, a new report warned Monday, putting fresh pressure on Congress to address the nation’s financial health as federal debt rises and the population ages.

Social Security and Medicare finances look grim as overall debt piles up - The Washington Post

The U.S. adult obesity rate increased from 21.2% in 1990 to 43.8% in 2022 for women, and from 16.9% to 41.6% in 2022 for men, according to the study, placing the country 36th in the world for highest obesity rates among women and 10th highest among men.

https://www.usnews.com/news/best-cou...%20among%20men.

[R&J in NJ]

Originally Posted by CoachKandSportsguy

Reforming Prior Authorizations

Copy if link doesn't work
So don't complain about cheap if you get stuck or subpar care
---------------------------------------------------------------

In April There Were 1,972 Patients Stuck in Mass. Hospitals

The latest MHA throughout report shows that in April there were 1,972 patients stuck in Massachusetts hospital beds awaiting transfer to the next level of care at a rehabilitation facility or home care.

The number jumped from the previous month’s total of 1,500 patients, due partly to rising patient volumes across the system but also because of new reporting from two large academic medical centers. While the new reporting was added to the report, it is important to note that the nearly 2,000 stuck patient figure is from just 38 of approximately 64 reporting hospitals in the state.

The inability of a patient to transfer to the next level of care affects not only the health and recovery of the patient, but also hospital finances and worker wellbeing (see next story).

The instability of the Steward Health Care system is contributing to the problem, as are other facility closures in recent years, including the increase in nursing home closures across Massachusetts. Even if beds were increased through pandemic-era flexibilities, it's unclear if there would be enough healthcare workers to staff them.

“Among other tools, we need Massachusetts to join the Nurse Licensure Compact (NLC) so we can simplify the licensure process for RNs to come and work in our state. And we need prior authorization reform so we can cut through the needless red tape hampering patient transfers,” said MHA’s Senior Vice President of Government Advocacy and General Counsel Mike Sroczynski. “We need meaningful healthcare legislation that reflects the realities and voices of today’s healthcare system. All of these things are within reach before the legislative session ends.”

Hospital Case Managers: Insurer Prior Authorizations a Problem
As the Massachusetts healthcare system reels from having nearly 2,000 patients stuck in Massachusetts hospitals and unable to transition to the next level of needed care (see above story), the collective focus of policymakers and the healthcare community is on how to resolve the problem.

Last week, MHA sat down with three case managers from a large hospital system to discuss the common problems they face once a patient has been assessed for discharge to some form of rehabilitative care. The case managers are clinical professionals who work with other clinicians – occupational and physical therapists, speech pathologists, and physicians, among others – as well as with skilled nursing facilities, health insurance companies, patients, and their families to orchestrate care transitions for patients. And the case managers all agree that the major problem with the process – the sand in the gears of care transitions – is the health insurance company prior authorization process, especially those from Medicare Advantage insurers.

MHA has filed legislation jointly with the Massachusetts Medical Society and Health Care For All that would address some of the difficulties patients and providers encounter from commercial health insurance companies’ prior authorization policies. The legislation would not eliminate prior auth and still allow insurers to use it as a means of controlling costs; but under the MHA-MMS-HCFA proposal, low-value prior authorization requirements would be eliminated and the process streamlined.

According to an MHA report, Massachusetts can remove as much as $1.75 billion in wasted costs through “sensible” insurance-related reforms – particularly through simplifying prior auth processes.

Delays of 5-to-10 Days

“Take, for example, the very common example of a patient who on Thursday gets assessed by the physical therapist, who recommends short-term rehab for the patient,” says one case manager. (The managers requested anonymity to avoid any further friction with the insurers with which they deal.) “One of our case managers talks to the patient’s family on Thursday and makes the referral for rehab, anticipating that the patient will be ready the next day.”

The first difficulty encountered is finding an open bed at a skilled nursing facility (SNF). But if a bed is found, the SNF will request authorization from the insurer for the transfer.

“And then we’re in a holding pattern,” the case manager says. “It takes two-to-three days for a prior authorization. And while we’re a seven-days-a-week operation, the insurers, especially the national Medicare Advantage plans, don’t work on the weekends. So now we’re into the following Tuesday to move a patient who we identified on the previous Thursday was ready to be transferred.”

The system case manager did note that interacting with Massachusetts-based insurers is generally easier than dealing with the national Medicare Advantage plans: “We can often get on the phone with a local insurer and say, ‘Please, can you move this patient to the top of the list.’”

Denials Extend the Process

A five-day transfer delay is troubling, but more disturbing is an insurer’s arbitrary denial of an authorization request, which will extend the transfer delay even longer.

“Often an insurer will say, for instance, that a patient can be managed at home even though we’ve conducted an assessment indicating that rehab is necessary,” one case manager says. “So we have to appeal it, supplying additional clinical information, or sometimes there is a peer-to-peer call between our physician and the insurer’s clinician. That means a hospital physician, who is supposed to be caring for patients, has to take time to coordinate a phone call, which often can be a laborious process to nail down a time, and often results on them being put on hold as they wait to talk to somebody.”

Appealing a denial can take days. And once the weekend comes, the process is shut down until the insurer’s utilization teams return to work on Monday morning. That means a patient can be stuck in a hospital bed for 10 days or more.

The Effect on Patients

When a patient is stuck in a hospital after being cleared for discharge, problems mount. Insurance companies typically pay hospitals a fixed amount per-patient, per-diagnosis. If a patient is stuck in a hospital for additional days after their course of care has been completed, the hospital generally does not receive any additional funding and often must absorb the additional costs on its own – to the tune of more than $400 million each year across all Massachusetts hospitals. Plus the occupied bed cannot be used to help ease overcrowding on a hospital’s emergency department.

But the main harm from the stalled prior authorization process is to the patient.

“Hospitals are not set up to provide multi-hour rehabilitation therapy to patients, so they’re deconditioning while they are waiting, which means it takes even longer for their recovery process once they do get into a rehab,” according to the case manager. And the longer a patient is forced to stay in a hospital, the greater chance he or she has of contracting a nosocomial infection.

Patients stuck in a hospital, aware of the prior authorization problem, may naturally try to contact their insurer themselves, according to the case manager. This generates another common problem since the 800-number on the back of an insurance card directs a patient to the insurer’s member relations department. Member relations will tell the patient the basics of their plan—namely, “Of course, you have the right to rehabilitation care.” Unfortunately, the utilization review department of the insurer is the one making the authorization denial – and the two departments rarely talk.

“So the patient loses trust in us, the people caring for them, because they do not believe what we are saying,” the case manager says. “It puts strain on the relationship between the hospital and the patient, it puts strain on the patient because they have to stay in the hospital, and it puts strain on us because we’re trying desperately to do right by patients.”

Solutions to the Problem

The case managers said much of the problem could be erased by two main actions. First, expanding an insurance company’s network of post-acute providers would allow a hospital to find a bed across the state that a patient’s insurer covers, thereby removing the fear of the patient paying out-of-network penalties or paying for their care entirely out-of-pocket.

But more importantly is the standardization of how to submit prior authorizations to the various insurers, and how quickly they are required to respond. Beginning in January 2026, under new federal guidelines, the timeframes for Medicare Advantage insurers to respond to prior authorization requests from providers will be reduced from 14 calendar days to 7 calendar days for standard requests while expedited requests remain at 72 hours. MHA recently wrote to the Centers for Medicare & Medicaid Services saying that even a 72-hour turnaround is too long – and the case managers agree.

But how about the argument that the insurers, although sometimes delayed in their responses, serve the important purpose of keeping costs in check?

“Prior authorization themselves are not the problem; it’s the processes associated with them," said one case manager from the interviewed hospital. "The insurance company is not physically at the bedside assessing the patient, so they have to rely on our clinical professionals. The insurers require a physical therapy evaluation, an assessment, and we provide that to them when we make a transfer request. We are physically with the patient doing that assessment; the insurance company isn’t. We can see that the patient is not able to ambulate and cannot safely go home; the insurance company can’t."

The case manager noted that if the patient didn’t have a Medicare Advantage insurer and had traditional Medicare instead, the transfer likely would be approved.

"Medicare Advantage insurers are required by law to provide the same if not more services than traditional Medicare, but they often do not," the case manager said. "And they’re doing a disservice to their patients by restricting them and causing long delays in getting to the next site of care.”

Enhancing Hospital-to-Home to Ease Capacity Crunch
While attempts to resolve the insurer prior authorization problem continues, the Healey Administration last week took another path to ease the capacity crisis: using American Rescue Plan Act Home and Community-Based Services funding to award $1.1 million to hospital and Aging Services Access Points (ASAPs) to expand the Hospital-to-Home Partnership Program.

The program helps discharge patients to their homes rather than to skilled nursing facilities or other post-acute settings. Determining the best location for a patient's post-acute-hospital care is still left to the discretion of the patient's care team.

There are currently 24 ASAPs across the state that help those over age 60 with care options, nutrition, food security, housing, financial wellness, transportation, and safety.

Why are you using this forum for answers? Write to your Congressman in that state.

[CoachKandSportsguy]

Originally Posted by R&J in NJ

Why are you using this forum for answers? Write to your Congressman in that state.

I will avoid using judgmental words, but its very tempting:

The post is being informative about choices people have in their medical insurance, and about situations they may experience, so that they are better prepared for such experiences, should they happen.

Many also do not know what happens in hospital operations, as they only see the face of nurses and doctors, but there is a lot more happening, and work that goes into a great hospital than just the nurses who attend to you during your stay. . there are people in large hospital operations who do work to make your stay better or shorter, and you may not know it, because you are just a patient. Maybe not at zero star hospitals, but at all the others, there are. .

[rsmurano]

I would never never go the Advantage plan route. If you are thinking about going this route, make sure you check these things out 1st:
1) something like 70% of medical procedures are not approved by the advantage provider. Since these policies are usually ran by insurance companies, they don’t approve medical procedures to save money. If you don’t believe this, check it out, and also look into why congress is looking into this. Why? Because Medicare doesn’t need approvals for medical procedures, so why do advantage plans?
2) I will always pay less with a supplement. No copays, $200 year deductible
3) once you are in the Advantage plan, you might never get into a supplement plan in the future. If you have any medical issues within the last 2 years, the supplement plans will not accept you. But when you turn 65, any plan has to accept you.

My insurance broker told me: if you can afford the supplement plan cost, keep it, this is the gold standard for Medicare coverage.
I agree!