How to Reduce Managed Care Denials at Your SNF

Managed care denials at skilled nursing facilities happen when a Medicare Advantage or other managed care plan refuses to pay for services that were provided to a resident. These denials are increasing as more Medicare beneficiaries enroll in MA plans — over 50% nationally — and plans tighten their authorization and utilization review processes. Reducing managed care denials requires a combination of upfront authorization management, concurrent clinical documentation, and systematic appeals when denials occur.

In This Post

• Why managed care denials are increasing
• The top reasons claims get denied
• How to prevent denials before they happen
• Building an effective appeals process

Why Are Managed Care Denials Increasing?

Two things are happening simultaneously. First, Medicare Advantage enrollment is at an all-time high — more than half of Medicare beneficiaries are now in MA plans. Second, these plans are tightening their criteria for approving skilled nursing stays. They’re using utilization review processes, AI-assisted coverage decisions, and shorter initial authorization windows to control costs.

A May 2025 AHCA survey of 363 nursing home providers found that MA plans are denying or delaying medically necessary post-acute care on a daily and weekly basis. The survey also confirmed what many facilities already know: most denials are overturned on appeal, but most facilities never appeal.

That last point is the key. The money is recoverable — if you have a process for going after it.

Top Reasons for Managed Care Denials

• Lack of prior authorization — The plan required approval before or during the stay, and it wasn’t obtained in time
• “Not medically necessary” — The plan reviewer determined the clinical documentation doesn’t support skilled level of care
• Exceeded authorized days — The plan approved a certain number of days and the resident stayed longer without an extension
• Untimely filing — The claim was submitted after the plan’s deadline (which varies by contract)
• Documentation gaps — Missing or incomplete records that the plan needs for payment processing

How to Prevent Denials Before They Happen

Know your contracts inside and out.

Every managed care plan has different rules. Some require prior auth within 24 hours of admission. Some have 72-hour windows. Some don’t require auth at all for the first 20 days. Your BOM needs a master reference sheet for every contracted plan that includes: auth requirements, filing deadlines, appeal timelines, and utilization review contact information.

Get authorization early and follow up relentlessly.

Don’t wait until day 3 to request authorization. Start the process on admission day — or before, if you know the resident is coming. Set calendar reminders for when authorizations expire. Request extensions before the last authorized day, not after.

Coach your clinical team on documentation.

When a managed care reviewer denies for “not medically necessary,” they’re saying the clinical record didn’t convince them. Your nurses and therapists need to document not just what they’re doing, but why the resident needs skilled services specifically. Why can’t a non-skilled caregiver provide this care? What would happen if services stopped? These are the questions reviewers are asking.

Hold weekly managed care meetings.

Your BOM, DON, and therapy director should meet weekly to review every managed care resident: Where are they in their authorized days? Is documentation supporting the continued need? Who is approaching their auth limit? These meetings prevent denials by catching problems before they become claim rejections.

Building an Appeals Process

Step 1: Track every denial in a log — date, plan, reason, dollar amount, appeal status, outcome. Review monthly for patterns.

Step 2: Appeal every denial where you believe services were medically necessary. Most plans have a Level 1 internal review that can be resolved within 30-60 days. If Level 1 fails, escalate to the Independent Review Entity (Level 2).

Step 3: Use denial patterns to fix root causes. If 80% of your denials from one plan are for “untimely auth,” that’s a process problem you can solve. If they’re all “not medically necessary,” that’s a documentation problem.

The Bottom Line

Managed care denials are not inevitable. They’re preventable with the right processes — and recoverable with consistent appeals. Facilities that treat managed care billing as an afterthought will continue losing revenue to plans that are more than happy to deny and move on. Facilities that build proactive systems will collect what they’re owed.

If managed care denials are eating into your revenue and your team needs help building a better process, SNF Solutions specializes in exactly this.

Contact us for a free consultation or call 407-977-8878.

— Nicole