Beneath the surface of every managed care denial is a larger story — one that involves clinical documentation, payer behavior, regulatory expectations, interdisciplinary communication, and leadership accountability. This session will help long-term care leaders uncover what is really driving denials, shortened authorizations, delayed decisions, and inconsistent payer practices. Attendees will gain practical strategies to strengthen managed care workflows, improve appeal outcomes, support nursing and administrative teams, and hold MCOs accountable when decisions do not align with coverage requirements or resident care needs.

Nurse Learner Outcome: 

Learner Objectives:

1. Describe current managed care and Medicare Advantage challenges affecting skilled nursing facilities, including common denial trends, shortened authorizations, delayed decisions, and payer practices that may differ from regulatory expectations.
2. Identify key CMS regulatory requirements and coverage principles that administrative and nursing leaders can use to evaluate payer determinations, support appeals, and hold managed care organizations accountable.
3. Recognize the role of nursing leadership, clinical documentation, interdisciplinary communication, and care coordination in supporting skilled need and strengthening managed care appeal outcomes.
4. Apply practical strategies to improve internal managed care processes, standardize appeal development, reduce avoidable administrative burden, and improve reimbursement outcomes.