A utilization reviewer at a Medicare Advantage plan may have a stack of requests and a few minutes for each. They are not reading your packet to understand the resident. They are looking for three answers. Does this person need skilled care every day? Why can't that happen at a lower level of care? What is the plan to get them home?

Packets fail when those answers are buried. The classic version is forty pages of hospital records faxed with no summary, so the reviewer finds nothing and denies for lack of documentation. The second version is a therapy evaluation that describes the resident well but never states function in measurable terms and gives no prior level of function to compare against.

A cover summary fixes most of it. One page, written by someone clinical, stating the skilled need in plain words (wound care with daily assessment, IV antibiotics, rehab five days a week), the functional baseline and goal, why home or assisted living isn't safe yet, and the expected length of stay. Put the clinical contact for a peer-to-peer call at the bottom, and make sure that person will actually pick up. Plenty of initial denials get overturned on a call, and plans do not wait long for a return.

Timing matters as much as content. Send the request the day the admission is accepted, not the day the resident arrives. For continued stay, put authorization expiry dates on the agenda at the weekly interdisciplinary meeting, so the clinicals for an extension go out before the current days run out and not after.

When a denial does come back, write down the reviewer's stated reason before anything else. Medicare Advantage plans generally have to follow traditional Medicare coverage criteria for SNF care, so an appeal that quotes the criteria and cites specific chart entries has something to stand on. An appeal that simply insists the resident needs the stay rarely moves anyone.

Facilities that can't give this a named owner often end up handing it off. LTCPro's prior authorization and case management support is one version of that for small SNFs and ALFs.

Author bio: Written by the LTCPro team. Visit the LTCPro team to see how the company supports skilled nursing and assisted living operators with billing, authorizations, payroll, and accounting.