News to Note – March 2026

• Quality Improvement Organization (QIO), Acentra, recently hosted a webinar about patient appeals of discharges from skilled nursing facilities (SNFs), and the data they presented was both eye-opening and exactly what one would expect.
• When a Medicare or Medicare Advantage (MA) patient receiving skilled care is to be discharged, the facility must give the patient a Notice of Medicare Non-Coverage which is similar to the Important Message from Medicare (IM) for hospital inpatients. Acentra reported that 93% of the discharge appeals they received were from MA patients when the MA plan notified the SNF that coverage was ending. In 48% of those cases, the QIO sided with the patient that skilled care was still necessary. 
• They also reported that, when the QIO sided with the patient, that process was often repeated over and over, with the MA plan again stating that coverage was to end and another notice provided to the patient. In fact, one patient received 12 such notices, meaning the QIO ruled in favor of the patient 11 times that skilled care was still needed after the MA plan tried to terminate coverage.
• It’s important to note that neither side’s data is entirely ethical or neutral. Under Medicare Part A, patients in SNFs are most frequently discharged on day 20, the day full coverage ends and daily copayments begin.
• On the subject of post-acute care, an article from doctors at the University of California San Francisco (UCSF) is a great review of the requirements and capabilities of home care, SNFs, inpatient rehabilitation facilities (IRFs), and long-term acute care hospitals (LTACHs). The article includes a table with details for each setting and a flowsheet to help determine the correct setting for patients. 
• With the new rules from the Centers for Medicare and Medicaid Services (CMS) about denials – in particular, CMS-0057-F – payors are trading traditional peer-to-peers (P2Ps) for “informational discussions” in which there is no ability to reverse the denial or add information to the record. 
• Hospital denial teams will need to act quickly, because peer-to-peer (P2P) discussions as we know them may soon disappear—despite CMS’s response to Dr. Ronald Hirsch last month clarifying that CMS-4208-F “did not prohibit plans and providers from engaging in voluntary P2P.”
• CMS also stated that after a denial is issued, an MA plan may reopen that determination if they have received additional information and can approve the case. Now how could they possibly receive such information? Via a P2P discussion.
• Similarly, the new CMS regulations requiring MA plans to notify patients within 72 hours if they issue a denial are leading many plans to ask hospitals to deliver the notice to the patient. Instead of outright refusing this request, consider what Tiffany Ferguson recommended in a RAC Relief listserv post: tell the payer the hospital will deliver the denial letter but, at the same time, ask the patient to sign the Medicare Appointment of Representative (AOR) form so the hospital can file a formal appeal on the patient’s behalf.
• Some hospitals are experiencing increased difficulty getting MA plans to approve patient transfers to long-term acute care hospitals (LTACHs). It’s important to remember that 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 they have a different payment structure under Medicare. 
• How to obtain MA approval for transfer to an LTACH? You’re certainly not going to tell the payer that the patient’s DRG has been all used up. Explain why the patient needs specialized care which your hospital doesn’t provide. Ensure your clinicians are documenting they have tried everything in their toolbox to wean the patient off the ventilator but failed, or that everything has been tried to heal the patient’s complex wound without success and now they need the special expertise available at the LTACH. Also, 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.
• In 2025, there were 2,682 denials of LTACH coverage by MA plans sent to Maximus; of those, only two were decided in favor of transfer. As such, winning an appeal without a compelling clinical reason is unlikely to happen. 
• Recently, a physician advisor posed a question on the RAC Relief listserv about patient status for a specific type of chemotherapy called bispecific T-cell engager (BiTE). BiTE is a one-time infusion of a patient’s own immune cells that have been modified to attack cancer cells — similar to CAR T-cell therapy — and requires hospital monitoring. The issue the physician raised was that the payer would not approve inpatient status for this high-risk treatment.
• Another physician advisor posted that their hospital had never performed the treatment as inpatient. Why? Because the DRG payment was less than the cost of providing the treatment and monitoring the patient as outpatient. In fact, the DRG payment didn’t even come close to covering the treatment’s cost.
• While in outpatient status, the patient would still get the correct treatment in a hospital setting with the appropriate monitoring. It’s important to remember that, by utilizing outpatient status, your hospital may be paid more than inpatient without any difference in the clinical care of the patient.
• Independence Blue Cross announced that, starting this month, they will pay hospitals less for inpatient hospitalizations that don’t meet InterQual Inpatient criteria. They will also only approve inpatient hospitalizations of six days or more without review. If you’ll recall, Aetna was the first payor to initiate this tactic, using MCG criteria and a five-day timeframe. This will be a growing problem for hospitals without access to both MCG and InterQual, as increasingly, effective appeals will need to demonstrate that the payer applied the criteria improperly.
• In the never-ending saga of expiring forms, while the Advance Beneficiary Notice (ABN) has remained expired since January 31 (but remains valid until the new version is approved, even though a proposed version has been posted), CMS finally released a new Medicare Outpatient Observation Notice (MOON) on February 20. It has changed slightly in format and content but is, for the most part, essentially the same, with a new expiration date in 2028. Hospitals have 60 days (by April 20) to implement the new form, and the wait for the new IM, Detailed Notice of Discharge (DND), and ABN continues.
• Since the Program for Evaluating Payment Patterns Electronic Report (PEPPER) has returned, it appears CMS has increased access, so hospital quality teams should be able to download it. The new report is little changed from the old version, but Dr. Sonya Siu, a physician advisor at Pennsylvania Hospital, noted that one measure didn’t make sense when she was reviewing her hospital’s PEPPER. The measure — single CC/MCC — notes the percentage of inpatient hospitalizations that have only one CC or MCC on the claim. This measure is not new, but in the old PEPPER, the 80th percentile was around 50%, and the new PEPPER has the 80th percentile around 5%. There is suspicion that the new contractor has somehow miscalculated the measure, and if it was mismeasured the same way for every hospital, you can still tell if you are an outlier and act. Dr. Hirsch has asked CMS to look into this and hopes to receive clarification soon.