MEDICARE ADVANTAGE PLANS ARE STRAIGHT-UP LYING TO YOUR BUBBE
Listen up, because AHCA just dropped a survey that proves what every SNF operator has been screaming about for years: Medicare Advantage is a full-time job of fighting with people who've never met your residents but somehow know better than your doctors.
Here's the Damage:
29% of nursing homes deal with MA denials EVERY. SINGLE. DAY.
Another 37% deal with it weekly. Do the math - that's two-thirds of SNFs wasting time arguing with insurance algorithms instead of, you know, providing healthcare.
But wait, it gets better (by which we mean infinitely worse):
67% of facilities have watched MA plans yank coverage while the medical team is literally saying "this patient isn't ready to leave."
Picture this: Your therapist says Mrs. Goldberg needs another week of rehab. Your nurse says she's not stable. Your doctor agrees. But some 25-year-old at Humana with a bachelor's degree in "denying everything" clicks "NOPE" and suddenly Bubbe's going home whether she can walk or not.
Here's the Part That Should Make Your Blood Boil:
When SNFs actually appeal these denials - you know, take time away from patient care to fill out forms and argue with robots - they win 57% of the time.
Read. That. Again.
More than HALF of all denials are complete BS. The insurance companies KNOW they're wrong. They're just counting on you being too busy to fight.
It's literally a game of "deny everything and see who has time to argue."
The Perfect Scam
And guess what happens when Mrs. Goldberg gets kicked out too early because UnitedHealthcare needed to hit their quarterly earnings target? She falls at home. Breaks her hip. Goes back to the hospital.
Then Medicare's Value-Based Purchasing program penalizes YOUR facility for the readmission that the insurance company caused.
You can't make this up. It's a perfect scam:
Insurance denies medically necessary care
Patient deteriorates and readmits
Government penalizes SNF for the readmission
Insurance company posts record profits
What AHCA's CEO Actually Said (in professional-speak):
"This constant hoop jumping is resulting in too many skilled nursing patients being discharged too soon against medical advice, threatening their recovery."
What He Meant:
"Insurance companies are playing Russian roulette with grandma's health to save a buck, and we're all pretending this is normal."
The Uncomfortable Truth:
More than half of Medicare beneficiaries are now in MA plans. This isn't a "some of our patients" problem anymore. This is "our entire census" territory.
And while some MA plans are making pretty promises about "improving prior auth processes," remember: they've been promising that since 2019.
The denials keep coming. The appeals keep working. The patients keep suffering.
Bottom Line:
Medicare Advantage sold itself as "more choices, better care." Instead, it's become a system where your medical expertise gets overruled by an algorithm, your time gets wasted fighting garbage denials, and when it all goes sideways, YOU get blamed.
The next time some insurance rep tells you they're "committed to quality care," ask them why 57% of their denials get overturned.
We'll wait.
CORRECTIONS FROM LAST EDITION
Last edition had a few inaccuracies:
Shlomy Chop had 7 homes in Wisconsin and is still keeping 3. The other 4 were purchased by Isaac Rami and Aharon Franco. Steven Reider isn't involved in this deal. These facilities will be under the name Amalfi Health. Also Chop didn't decide to leave, his lease was up. Rami and Franco are serious operators and have no doubt they will do well after what they pulled off with their purchase of 13 homes from Guardian 8 months ago.
Last edition we featured The Big Plan but didn't put Isaac Stark's contact info. Here it is:
Isaac Stark
📞 347-933-3399
📧 Isaac.stark@exponentialplatform.com
Last edition we mentioned info we got from Hiten Samtani in the promote as well and didn't give him a shoutout. Check him out!
