Federal Auditors Put Numbers on Medicare Advantage Denials

The Medicare Advantage grievance that roughly 700 nursing-home operators carried to Capitol Hill last week now has a federal audit behind it. A Department of Health and Human Services inspector general report released June 11 found that patients in some of the nation's largest Medicare Advantage plans were denied prior authorization for rehabilitation and other critical services at unusually high rates, NBC News reports. 'These denial rates are quite staggering,' said Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh.

The operator side of the ledger has a named case. Hunterbrook Media published a five-month investigation June 8 alleging The Ensign Group's business model relies on delivering inadequate care to patients while gaming data on quality, with patients dying. Read it with the disclosure attached: Hunterbrook Capital, the outlet's affiliated fund, is short Ensign stock at publication, so the reporting arrives carrying a financial position. It still lands in a system where the federal staffing floor that would have policed care hours was repealed in February.

States are moving into that vacuum. Stateline reports a growing number of legislatures are considering financial transparency and oversight requirements for private equity-backed facilities. The case file is concrete: Genesis HealthCare faces lawsuits or investigations in Vermont and several other states over alleged patient neglect and abuse, and nearly 200 residents of St. Joseph's Center in Trumbull, Connecticut were evacuated twice, once after Legionella was found in the water system and again two months later over critical facility failures. Meanwhile Hireology's industry read of the repeal is blunt: the compliance math changed, the problem did not, and 90 percent of nursing home providers still report recruiting is difficult.