THE CHALLENGE
LA recent report identified prior authorization request denials by Medicare Advantage Organizations (MAOs) for post-acute care to be a particular area of concern. The report, published by the Department of Health and Human Services Office of Inspector General (HHS-OIG), raised concerns that the MAOs may be inappropriately denying care, evidenced by the 95% overturn rate in favor of the patient.1 The report highlighted that the enrolled patient, or their provider, appealed just 18% of skilled nursing facility (SNF) denials. This statistic raises an additional concern about the denials that were not appealed, potentially depriving enrollees of the full value that the MAOs were paid to authorize.
Across the US, an estimated 14% to 20% of all Medicare patients require an SNF stay following their hospital discharge. Traditional Medicare patients transition directly to an SNF approximately 20% of the time, while MA patients were only discharged to SNFs about 13% of the time.2 This statistic, in addition to the 95% overturn rate on these denials, highlights that hospitals and patients should be holding the MAOs accountable, and appealing prior authorization denials for skilled-level care at a facility post discharge.
THE SOLUTION
SNF denials are rampant, and they deprive patients of skilled nursing care at the most vulnerable time in their lives. SNF denials can also create a bottleneck. For example, a patient being denied post-acute care in an SNF may need to spend more time in the hospital before being discharged. This increases the patient’s length of stay (LOS), leading to compromised patient safety. Further, there is an increased likelihood of readmission when a patient is denied necessary post-acute care, affecting the hospital’s reimbursement and quality of care. These factors emphasize the importance of appealing SNF denials, but operationally, this can be challenging due to the narrow window the payer requires for a peer-to-peer (P2P) to transpire. AppriseMD can help.
AppriseMD physician advisors take an aggressive approach to overturning denials, and we make it easy. With no contract minimums, hospitals can send cases that they do not have the internal bandwidth to handle. Getting these denials overturned are integral to reducing LOS and readmissions. Further, patient satisfaction is heavily influenced by a hospital’s discharge process, which is why hospitals are leaning into ways to positively impact the transition of care from the acute setting.
Recently, a hospital referred a SNF denial to AppriseMD for review with the MA medical director. After reviewing the medical record and engaging in a timely P2P, AppriseMD was able to overturn the denial by focusing on the patient’s persistent decline in several modalities of therapy.
CLINICAL SUMMARY
An 85-year-old female, assisted-living resident with a history of atrial fibrillation on Eliquis, thyroid disease, diabetes mellitus, and hypertension, presented to the emergency department after two unwitnessed falls. She denied head trauma, loss of consciousness, or injuries, but facility staff reported new word-finding difficulty and speech changes.
On arrival, she was noted to be hypertensive at 208/90. Physical examination showed mild tenderness on the base of the neck and lower thoracic spine, but there was no swelling or deformities noted. The patient received treatment for a hypertensive emergency, multiple falls, and aphasia, and underwent an extensive evaluation. She received two doses of IV labetalol with close blood pressure monitoring for permissive hypertension. She was admitted for continued monitoring with frequent neurological checks and repeat imaging. Further evaluation confirmed an acute middle cerebral artery (MCA) stroke. She also required telemetry monitoring with ongoing adjustments of her blood pressure medications and serial monitoring of her blood glucose due to some hyperglycemia with insulin adjustments.
She underwent evaluations by physical therapy (PT), occupational therapy (OT), and speech therapy. She completed activities of daily living (ADL) transfers with contact guard assist and ambulated approximately 100 feet with a front-wheeled walker, demonstrating a short, shuffling gait and notable fatigue. Speech therapy noted moderate-severe receptive and expressive language deficits with impaired ability to communicate basic wants and needs, timely and effectively. Given her high fall risk, reflected by a Tinetti score of 10, and persistent speech and functional deficits, placement in an SNF was recommended for continued self-care, transfer, mobility, and communication rehabilitation. When the SNF stay was denied by the patient’s carrier, the hospital referred the case to AppriseMD. Following a successful overturn of the SNF denial, the patient was transferred to the SNF on hospital day 3 in stable condition.
SNF DENIAL OUTCOME
A SNF denial P2P was completed with an AppriseMD physician advisor and the MA medical director. The P2P review involved a discussion of the 85-year-old patient living in an assisted living facility (ALF) who presented in the hospital due to multiple falls. The physician advisor communicated that the patient, at baseline, was able to perform ADLs and walk to the dining room with a walker. The patient reported two falls before admission and was found to have expressive and receptive aphasia after the second fall. Imaging confirmed an acute MCA stroke, which the physician advisor noted required skilled care, not just custodial care.
AppriseMD also addressed that the patient was evaluated by PT, OT and speech therapy. She was able to ambulate with an assistive device for approximately 100 feet, but was fatigued and had difficulty walking the 200 feet required to ambulate to the ALF dining area. Despite the distance that the patient was able to ambulate, she was unable to care for herself. The AppriseMD physician advisor highlighted that the patient’s decline from her baseline function required assistance with ADLs, representing acute and significant declines in independent transfers, ambulation, and performance of most ADLs. AppriseMD also verbalized the persistent, significant, expressive, and receptive aphasia noted in the patient’s speech therapy.
The declines in all therapy modalities were noted from the patient’s baseline, and the physician advisor discussed how the patient would benefit from daily, skilled therapy at an SNF. AppriseMD successfully petitioned for a reversal of the denial, resulting in the MAO authorizing SNF post-acute care following discharge.
ABOUT APPRISEMD
AppriseMD provides denial management and physician advisory solutions to help hospitals and health systems optimize the revenue cycle with data transparency and operational efficiency.
SOURCES
- Department of Health and Human Services Office of Inspector General, “Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials,” June 8, 2026.
- Koenig, Lane, PhD, “Medicare Advantage Enrollees Almost Half as Likely to Receive Inpatient Rehabilitation as Compared to Fee-for-Service Enrollees.” KNG Health Consulting LLC. November 20, 2025.