95% of appealed Medicare Advantage SNF denials were overturned. Only 18% were appealed.

OIG looked at Medicare Advantage denials for SNF admission. In the month they studied, plans denied 12% of requests. Of the denials that got appealed, 95% were overturned.

Only 18% were appealed.

Sit with those two numbers together. If nearly every denial you challenge gets reversed, the denial wasn't a clinical judgment. It was a bet that you wouldn't challenge it.

And the figure I can't stop looking at: for enrollees already living in a nursing home, the denial rate was 40%, against 11% for everyone else.

Most of the reaction to this has been about appeals staffing, which is fair. There's a quieter version of the same problem inside the building, on continued stay.

Continued-stay authorization turns on documented functional progress. Progress requires attendance. And the most common reason a resident doesn't attend is that something hurts and the regimen hasn't been revisited since admission.

So every refused therapy session is also a documentation event. It's the plan's best argument that the resident isn't progressing, written by your own chart.

Your case managers are already fighting the denials. The upstream fix sits on the medical side, before there's anything to fight about.

If you run a building, do you know your appeal rate? Not your denial rate. Your appeal rate.