Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials (OEI-09-16-00410)

October 6, 2018


What OIG Found

When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014-16, overturning approximately 216,000 denials each year. During the same period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers. The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided. This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment. During 2014-16, beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.

Centers for Medicare & Medicaid Services (CMS) audits highlight widespread and persistent MAO performance problems related to denials of care and payment. For example, in 2015, CMS cited 56 percent of audited contracts for making inappropriate denials. CMS also cited 45 percent of contracts for sending denial letters with incomplete or incorrect information, which may inhibit beneficiaries' and providers' ability to file a successful appeal. In response to these audit findings, CMS took enforcement actions against MAOs, including issuing penalties and imposing sanctions. Because CMS continues to see the same types of violations in its audits of different MAOs every year, however, more action is needed to address these critical issues. Read the full report here. https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf



RAI Manual Errata File

October 6, 2018


An RAI User's Manual Errata file has been posted to the CMS MDS 3.0 RAI Manual webpage at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html

The Errata file, titled MDS 3.0 RAI User's Manual (v1.16R) Errata (v1) October 1, 2018, is located in the Downloads section of the webpage and contains the RAI Manual Change Table and associated replacement pages.

Revisions include:

  • Chapter 3, Section J, Item J2000 Prior Surgery, amended criteria for Major Surgery. Specifically, the removal of the general anesthesia criterion.
  • The examples for coding J2000 have been corrected to remove the criteria of general anesthesia
  • Updated manual pages are marked with the footer "October 2018 (R)"

Providers who use a print version the RAI User's Manual should print the manual replacement pages and incorporate the replacement pages into the printed manual. A revised manual has not been posted, just the Errata



Nurse Aide Registry Annotation List

October 6, 2018


Attached, for your information, is a listing of all nurse aides who have had substantiated findings of resident abuse, neglect or misappropriation of resident property entered on the Pennsylvania Nurse Aide Registry as of October 3, 2018. The Nurse Aides names that have been added since the last issue are bolded.

Verification of a nurse aide's status must still be done before hiring to verify eligibility for employment in a nursing care facility. An individual nurse aide's status may be verified by accessing the twenty-four hour online access to the registry via the Department of Health website at www.health.pa.gov/ . Once this site is accessed, click on "Healthcare Facilities" at top of page and next select "Registries" and "Nurse Aides". Next click on "Nurse Aide Registry On-line". Choose "Pennsylvania Department of Health" under the program once on the Pearson Vue Pulse portal page and use "Registry Search".

If you would like additional information or have any questions, please feel free to contact Division of Nursing Care Facility staff at 717-787-1816.

Annotation List October 2 2018.pdf



Forms that are required to be completed and given to the State Agency during recertification surveys

September 30, 2018


Attached are forms that are required to be completed and given to the State Agency during recertification surveys. They are being posted in a format that can be saved and provided to the survey team upon entrance. Please note the Entrance Conference Worksheet for NHA is being provided in addition to a State Entrance Conference Checklist and a SNF Beneficiary Protection Notification form.

CMS-671 (06-2018).pdf

CMS-672 (05-12).pdf

Entrance Conference Worksheet for NHA.pdf

Matrix with Instructions.pdf

SNF Beneficiary Protection Notification.doc

State Entrance Conference Checklist.doc

Survey in Progress Door Sign.pdf



Maintenance - Tuesday, 10/9/2018, 6AM-10AM

September 30, 2018


Attention: SAIS, POC Public Web, POC Facility Web, ONL, ERS , HCSIS (DOH Side) and PSA (DOH Side) application users.

The systems listed above are being upgraded beginning Tuesday, October 9th at 6:00 AM until approximately Tuesday, October 9th at 10:00 AM.

Users will be notified when the systems become available; please do not use them before being notified or data could be lost.



Susan Williamson Question/Answer

April 30, 2018




Urinary Tract Infection (UTI) Event for Long-term Care Facilities

April 29, 2018


CDC Article

Urinary Tract Infection (UTI) Event for Long-term Care Facilities

Evidence-Based Practices to Prevent HAIs/CAUTI and Improve Resident Safety

April 12, 2018




Transition to Payroll-Based Journal

April 12, 2018


Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on Medicare.gov and the Five Star Quality Rating System

Transition to Payroll-Based Journal

WOCN 50th Annual Conference

February 15, 2018


PADONA is not endorsing the conference, but making the information available to you.

WOCN 50th Annual Conference

PCOM NHA Continuing Education

February 14, 2018


Information is attached for the Philadelphia College of Osteopathic Medicine Federal Regulations Update and Review (June 12 and 13, 2018) as well as the Nursing Home Administration 120 hour Course (March 6-June 26, 2018)

PADONA is not endorsing these, but making the information available to you

PCOM NHA Continuing Education

LeadingAge PA/PADONA Educational Series - Next Session on Tuesday, January 23rd

January 15, 2018


Kelly O'Neill and Barbara Stadelberger will address Resident Rights. They will address Beneficiary Notices, Personal Funds, Environment-safe/clean, & Resident Council.

LeadingAge PA/PADONA Educational Series - Next Session on Tuesday, January 23rd

LeadingAge PA/PADONA Educational Series Beginning Tuesday, January 9th

January 4, 2018


LeadingAge PA/PADONA Educational Series Beginning Tuesday, January 9th

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