Some Managed Care Plans Lift Restrictions on Skilled Nursing Coverage Amid COVID-19 — But Not All

Multiple managed care plans have made changes to their procedures for admissions to the skilled nursing setting amid the ongoing coronavirus pandemic, with several major companies suspending prior authorization requirements for admissions to a skilled nursing facility. The changes, however, are not uniform — and that’s if the managed care organization (MCO) chooses to make such a change at all.

These variations in approach match what Susie Mix, CEO and president of the managed care contract and consulting firm Mix Solutions, has seen — though she noted that like much else related to COVID-19, “things are changing daily.”

The real question will be what happens to claims in the future, she told SNN via e-mail.

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“Will they actually pay us when there is no pre-auth number as they are saying they will?” she wrote. “It is absolutely necessary to put these revisions in place, and I am happy that the health plans are doing it. I just hope that in a couple months, when we have followed their new guidelines, they are able to adjudicate.”

Prior authorizations waived — mostly

Starting March 25 for a period of 30 days, Aetna waived initial pre-certification/prior authorization for admission to post-acute facilities, including SNFs and extended acute rehabilitation, for all commercial and Medicare Advantage plans.

Aetna, which is part of the Woonsocket, R.I.-based CVS Health (NYSE: CVS), has approximately 2.32 million Medicare Advantage members, according to its most recent 10-K form filed with the U.S. Securities and Exchange Commission.

The Bloomfield, Conn.-based Cigna waived prior authorization for the transfer of non-COVID-19 patients from acute patient hospitals to long-term acute care hospitals, starting March 23 through May 31. The insurer “has also waived prior authorizations for the transfer of its patients to other in-network subacute facilities, including skilled nursing facilities and acute rehab centers,” according to its March 23 press release announcing the waivers.

“In-network” is the key phrase to note in Cigna’s announcement, according to Guidance Care HMO, a managed care consulting firm based in Lakewood, N.J., that compiled the memos and announcements from the managed care companies and shared them with Skilled Nursing News.

An out-of-network facility, however, would still require authorization unless the Cigna member is going to use their out-of-network benefits.

UnitedHealthcare (NYSE: UNH), which has approximately 5.27 million Medicare Advantage patients according to its most recent 10-K form, suspended prior authorization requirements for the post-acute setting from March 24 through May 31, 2020.

Anthem’s affiliated health plans also suspended prior authorization requirements for hospital inpatient transfers to lower levels of care, though it requested “voluntary notification via the usual channels to aid in our members’ care coordination and management” in an update dated March 26.

UnitedHealthcare, Cigna, and Aetna all still required notification of the admission to the new setting, on varying timelines.

Humana appears to be an outlier; the Medicare Advantage giant — which has about 3.58 million members according to its 10-K form for the year ending December 31, 2019 — has removed preauthorization requirements in most instances, “except for post-acute levels of care,” according to its COVID-19 benefits update dated March 23.

The plans will likely make additional changes as COVID-19 cases continue to spread, but at least some of the current alterations might be of help to operators, as one reimbursement expert bluntly noted.

“COVID apparently forced traditional Medicare Advantage plans to read the laws governing their fundamental obligations,” Marc Zimmet, president and CEO of Zimmet Healthcare Services Group, told SNN via e-mail. “So I commend them for raising the bar to the level of human decency.”

Providers focus on flexibility

The Centers for Medicare & Medicaid Services (CMS) has put an emphasis on freeing up hospital beds to prepare for an influx of COVID-19 cases, and to that end has implemented a waiver of the three-day stay requirement for Medicare coverage of a SNF stay. Mix also noted that the largest nursing home trade group in the country, the American Health Care Association (AHCA), recently released a template letter that SNF providers can use to ask managed care organizations for “a reduction in documentation requests.”

The letter template, included in guidance from AHCA released on March 24, provided several requests for MCOs, including:

  • The suspension of prior authorizations for admittance from the hospital to the SNF or the automatic approval of the first three to five days of every SNF stay and admission without retrospective denial.
  • The suspension of all pre-payment audit requests, as well as the postponement of post-payment audits on claims for at least 180 days.
  • The reduction of updates and documentation requests
  • An easing of the standard definition of a “clean claim” and paying SNF claims within 14 days
  • Carving out the costs of COVID-19 drugs with an allowable 365 days for billing

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