Medicare Advantage Peer-to-Peers, LTACH Transfers, and Outpatient Infusions

While many in hospitals find understanding the new regulations on Medicare Advantage (MA) plan denials challenging, it appears that the payers are also having a difficult time adopting their practices.

While we have talked a lot about Aetna’s policy and its “severity review,” another payer released a policy indicating that they would be issuing an “intent to deny” notice to hospitals – and then giving the hospital 60 minutes to contact them for a peer-to-peer, or else the admission would be formally denied and the only option would be a written appeal.

And to make it worse, the notice would not be sent to the hospital, but simply entered into the payer’s system, requiring the hospital staff to check that portal every 30 minutes for new notices. But that policy lasted all of one month, as this payer then took away this opportunity, humbly stating that they were unable to get the peer-to-peers scheduled expeditiously, so providers must suffer the consequences.

But perhaps as a consolation prize, the payer will still allow “informational” peer-to-peer discussions, wherein their medical directors will discuss the case with the provider, but without any power to reverse the denial or add information to the record. I do not expect many providers to take them up on that offer.

Moving on, I was contacted by a hospital about their increasing difficulty getting MA plans to approve transfers to long-term acute care hospitals (LTACHs). Unfortunately, I had to agree with the payers here. As I have discussed in the past, LTACHs are acute-care hospitals, just like other acute-care hospitals. The only regulatory difference is that their patients have an average length of stay of 25 days or more. And of course, they have a different payment structure under Medicare.

Now, how do you get a MA patient approved to transfer to an LTACH? Imagine an acute-care inpatient you want to transfer to a tertiary care hospital for specialty care that you do not offer. You are not going to tell the payer that you want that bed opened up for another patient; you are going to explain to them why that patient needs specialized care you do not provide. You will explain, and have the doctors document, that you have tried to wean the patient off a ventilator, but failed, or that everything has been tried to heal their complex wound without success, and now they need the special expertise available at the LTACH.

And remember to have the patient’s family call the payer to advocate for approval of the transfer, to give their loved one the best chance of recovery.

I will note that in 2025, there were 2,682 denials of LTCAH coverage by MA plans sent to Maximus, and of those, only two were decided in favor of transfer, so expecting to win at appeal without a compelling clinical reason is likely a losing proposition.

It is also worth noting that many have heard that to be accepted at an LTACH, the patient must have spent three days or more in the ICU.

That is not true. By regulation, LTACHs can accept any patient with an expected length of stay of more than 25 days. But they only get paid the special LTACH payment rate from Medicare if the patient spent three or more days in the ICU – or spend at least 96 hours on the ventilator upon arrival at the LTACH. Other cases are paid at a lower rate.

Unlike short-term acute-care hospitals that must follow Emergency Medical Treatment & Labor Act (EMTALA) regulations, LTACHs, just like inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) and home care agencies, can choose which patients to accept, even if the decisions are purely financial.

Finally, there was a recent online post worthy of mention. A doctor asked about admission status for a specific type of chemotherapy called Bispecific T-cell engager, or BiTE. It is a one-time infusion of the patient’s own immune cells that have been modified to attack cancer cells, similar to chimeric antigen receptor therapy (CAR T-cell) treatment, which requires hospital monitoring. The problem is that the payors would not approve inpatient admission for this very risky treatment.

Well, another physician advisor posted that they never perform the treatment as inpatient. Why? Because the Diagnosis-Related Group (DRG) payment is less than the payment to provide the treatment and monitor the patient as outpatient – and in fact, the DRG payment does not come close to covering the cost of the treatment. The patient will be getting the correct treatment, in a hospital setting with the appropriate monitoring, and the hospital will be paid more as outpatient.

Remember, before fighting for inpatient, make sure that’s really the status you want.