Advocacy & News

Survey: Medicare Advantage Denials

Please complete by January 31st, 2020

Purpose and Overview: The purpose of this survey is to determine the rate at which Medicare Advantage (MA) plans hinder access to Inpatient Rehabilitation Hospitals and Units through the use of prior authorization. To accomplish this, AMRPA is requesting members submit information on the results of prior authorization requests submitted to MA plans. This data will be aggregated for use in AMRPA’s policy efforts as the Association works to address the use of prior authorization in the Medicare program.

AMRPA is requesting data for calendar years 2017 and 2018. The data will be kept separate for each year in order to analyze trends from one year to the next. We are also asking for data on individual plans, if available, which can be provided in the additional sheets provided in the document. The survey will also ask for detailed information on the conditions of patients being approved or denied access, if available. Hospitals do not need to complete every field, though we ask that you provide identifying information for your facility. AMRPA does not anticipate all hospitals will have all of these data points. Hospitals are asked to submit as much or as little data as they are able, but it is important to submit it in a uniform fashion.

Download and Upload Instructions: 

  1. Download the AMRPA Medicare Advantage Denials Survey Spreadsheet.
  2. Complete the Spreadsheet using the instructions below.
  3. Re-upload the Spreadsheet online here

Survey Instructions:

Specific Data Fields: Note that each sheet is broken down by year. Please only include data from the year specified for that sheet. In addition, AMRPA has identified four fields that are most crucial to this survey. If hospital is unable to complete other fields, we ask that hospital, at minimum, complete the four fields indicated in red and with an asterisk* below. Further, if hospitals keep information broken down by each MA plan (i.e., company) we ask that you add additional sheets and fill in the information for each plan. Finally, please note that a peer-to-peer discussion is not technically an appeal. Please keep that in mind when indicating how many patients were admitted or denied before or after an “appeal.” Finally, there is a “narrative” worksheet that will allow you to include specific patient stories (PHI redacted) regarding inappropriate denials of access to care. Finally, please note that there are several worksheets included in the file, which can be selected by their tabs at the bottom of the excel file. 

Total MA Patients Referred to Hospital: This field is intended to provide a sense of how many MA patients are screened by rehabilitation hospitals for potential admission. This includes patients that the hospital both did and did not ultimately attempt to admit.

Total MA Prior Authorization Requests by Hospital*: This field is the total number of patients that the hospital requested prior authorization for admission from an MA plan, regardless of whether the request was approved or denied.  

Total Approvals Without Appeal: This is the total number of prior authorization requests to MA plans that were approved upon the first request, without the need for an appeal, and regardless of whether the patient was ultimately admitted. This includes patients approved for admission after a peer-to-peer discussion.

Total Peer-to-Peer Discussions Required: This is the total number of peer-to-peer discussions your hospital was required to conduct for MA beneficiaries, regardless of whether patient was ultimately admitted or not.

Average Staff Time Spent on Peer-to-Peer (per patient): This is an estimate of the total staff time the hospital spends on peer-to-peer discussions, per patient. This includes physician and anyone else involved in arranging or preparing for the discussion.

Total Initial Denials*: This is the total number of prior authorization requests to MA plans that were initially denied by the MA plan, prompting the need for an appeal. This includes patients that were initially denied, even if ultimately approved after successful appeal. This does not include requests approved after a peer-to-peer discussion with no further action needed (peer-to-peers are not technically appeals).

Primary Reason Given for Denials (pick one from drop down)*: This is the reason given most often by MA plans to the hospital for initially denying a request for admission for an MA beneficiary. If other reasons not listed, or multiple reasons are given at a nearly equal rate, please explain in writing in adjacent cell. If you click on the “total” cell, a drop down menu should appear.

Total Appeals: This is the total number of denied prior authorization requests that were appealed by the hospital or beneficiary. This includes all appeals, regardless of whether successful or not.

Denied Appeals: This is the total number of appeals by hospital or beneficiary to an MA plan that were not favorably overturned to allow admission to IRF. This does not include patients that did were denied after peer-to-peer but did not further appeal. Those patients would be considered only an initial denial.

Total Admissions After Successful Appeal: This is the number of patients who ultimately were admitted to the hospital after a successful appeal. This should not include patients who had a successful appeal but did not ultimately get admitted to hospital.

Total MA Admissions*: This is the total number of MA patients admitted to the hospital that year, regardless of whether admission was due to initial approval or a successful appeal.

Condition Columns: Note that next to the “Total” column, there are several condition columns. If hospitals have MA admissions broken down by condition, we ask that they indicate that data in the columns. If Hospitals have MA admissions data broken down using different categories, such as Rehabilitation Impairment Category (RIC), we ask that you replace the condition columns with other titles, but do not change the row categories.

Note: Please do not include any Protected Health Information (PHI) in your survey results. Any documents containing PHI will be immediately destroyed and not included in survey results.