Delays, denials harming post-acute care

Not only do Medicare Advantage plans place roadblocks to admitting patients to hospitals, they frequently deny or delay post-acute care and long-term acute care. MSSC physicians say this can cause patients to stay in hospitals longer than needed or put them at risk when they leave, which can lead to hospital readmissions.

“We experience delays in the response time and often denials for placement,” said Chady Sarraf, MD, hospitalist medical director at Ascen­sion Via Christi. “We appeal some denials, and we have to go through peer-to-peer interviews with the insur­ance medical director to make them change their mind and approve the patient placement.”

In addition to taking up staff time, the protracted process can negatively affect patient recovery time and safe discharge planning, Sarraf said. It also means patients are occupying hospital beds that others need.

Christopher Cassidy, MD, medical director at the Wesley Medical Center Emergency Department, sees the same problem.

“The time it takes for a patient to be accepted into post-acute care — and then actually transferred — creates significant bottlenecks throughout the hospital, which in turn directly affects the ER,” he said. “We have a large portion of patients waiting in the ER (in hallway spaces, rooms and at times even the waiting room) for an inpatient bed.”

The delays are not just a Wichita problem. The U.S. Senate Permanent Subcommittee on Investigations issued a report last October titled “Refusal of Recov­ery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care.” It found that MA insurers used algorithms to deny prior-authorization requests for post-acute care at rates three to 16 times higher than overall denial rates.

James Walker, MD, medical direc­tor of the stroke center at Via Christi St. Francis, said Medicare Advantage plans also frequently deny or delay care when patients are ready to leave the ICU and move to long-term acute care, such as patients with devastating neurologic injuries.

Walker recalled one case in which he spent nearly an hour talking to insurance company representatives, over multiple days, outlining the need to transfer a patient to long-term acute care, only to be denied without any explanation or recourse. He noted how it was in the insurance company’s financial interest to deny the transfer and keep the patient in the ICU, because the MA plan capped its payments based on the average ICU stay for a par­ticular diagnosis, and the patient had exceeded the average stay.

“How is that even legal?” he asked.