IHA Small & Rural Meeting: Addressing Medicare Advantage Payment Denials
Enrollment in Medicare Advantage (MA) in rural communities has grown significantly over the past 15 years, resulting in new payment issues for hospitals and health systems. Attorney Richelle Marting, JD, addressed these issues yesterday at the 2025 IHA Small & Rural Hospitals Annual Meeting in her session, “Uncovering How Medicare Advantage Plans are Not Paying You – Finding Solutions.”
Increasingly, MA plans may be applying criteria for coverage and payment that are more restrictive than traditional Medicare, despite the Centers for Medicare & Medicaid Services’ (CMS) longstanding policy that MA plans must make medical necessity determinations that are no more restrictive than traditional Medicare, Marting noted.
“The OIG was doing a study and found that Medicare Advantage plans were kind of creating their own clinical criteria—things that didn’t exist in traditional Medicare rules, things that don’t exist in traditional Medicare coverage,” said Marting, noting MA plans had a very high denial rate for covering services or authorizing services, as well as a very high overturn rate when denials are appealed.
MA plans use diagnosis-related group downgrades, clinical validation and post-claim status changes to significantly reduce reimbursement, Marting said.
“A lot of Medicare Advantage plans will downgrade or find ways to—maybe not deny the entire stay—but deny portions of the stay,” noted Marting. She said, with regard to prior authorization, CMS has reiterated now in numerous regulations and manuals that if the MA organization preauthorized the admission it would be a violation to later deny payment based on a decision that level of care isn’t necessary.
She highlighted a response strategy that can effectuate real results and changes includes knowing the rules, expending early and frequent efforts to enforce them, and knowing avenues to amplify them. She emphasized “it took months of consistently filing complaints with CMS to see a change in behavior,” and underscored that, “Medicare Advantage plans do not like when star ratings get messed with.” She said, “It became very clear to us when we were beginning to hit a threshold that seemed it may be starting to impact star ratings,” saying consistently filing complaints with CMS prompted engagement from the plans who reach out to address the issues.
View Marting’s presentation slides here. See IHA’s X, Facebook and LinkedIn pages for more about the annual meeting.
Building Trust in Communities: Keynote at IHA Small & Rural Meeting
Andrew McCrea grew up in a small community and saw how building relationships helped shape his future. At the 2025 Small & Rural Hospitals Annual Meeting yesterday, the Oscar-winning broadcaster delivered a keynote address calling on hospital leaders to foster deeper connections with the communities they serve.
“In a time in which we have so much going on, you also have to live the future simultaneously,” said McCrea, who hosts the “American Countryside” radio program and is a farmer in rural Missouri. “Some things have to change even if they work in the present. It’s building that mindset inside the hospital walls that will transform things outside the hospital walls.”
His address, “Beyond the Hospital Walls: Building Trust and Transforming Communities,” identified three key areas to consider when engaging the community: make it personal (in a good way); make it purposeful, meaning providing what people need and want; and have perspective by learning to live and lead through the eyes of others.
“We need to heal the people inside the walls, but we won’t be able to do this until we get outside the walls,” McCrea said. “How do you get outside your walls and build trust within your community? You invest in and empower your people.”
View MCrea’s presentation slides here. See IHA’s X, Facebook and LinkedIn pages for more about the annual meeting.
Still Time to Register: HNI June 17 Legislative Recap Program
Health News Illinois (HNI) is assembling a panel of experts for its annual recap of what the latest Illinois legislative session means for healthcare. On June 17, the panel will analyze the budget and highlight the significant healthcare bills sent to Gov. JB Pritzker.
Click here to purchase tickets and access more information about the program.
Dave Gross, IHA Senior Vice President of Government Relations, will join the panel, which includes:
- Rep. Robyn Gabel (D-Evanston), House Majority Leader
- Jud DeLoss, CEO, Illinois Association for Behavioral Health
- Garth Reynolds, Executive Director, Illinois Pharmacists Association
Analysis: Federal Health Cuts in OBBBA Threaten Rural Hospitals
Proposed healthcare funding cuts in the One Big Beautiful Bill Act (OBBB) could jeopardize the future of more than 300 rural hospitals nationwide, according to
new data from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. The findings, released yesterday at the request of
Senate Democrats, warn that significant reductions in Medicaid or Medicare payments could worsen financial instability among rural hospitals. According to the center’s analysis, these pressures may force hospitals to scale back services, convert to other types of facilities or shut down entirely.
New Clinical Guidelines Prioritize Lifestyle Interventions for Type 2 Diabetes
Over 38 million people in the U.S. have diabetes, and it is the eighth leading cause of death. Of all people with diabetes, 90% to 95% have type 2 diabetes. The first-ever clinical guidelines
published by the American College of Lifestyle Medicine offers a comprehensive, evidence-based roadmap for clinicians to effectively incorporate therapeutic lifestyle behavior interventions as a mainstay of type 2 diabetes treatment.
The organization said that although there are nearly 1,000 guiding documents for diabetes in the medical literature, and more than 350 pages of standards from the American Diabetes Association, they may not offer details and practice advice on lifestyle change. The new guidelines not only makes the case for lifestyle changes as the starting point in managing type 2 diabetes, but also offers clear, practical, evidence-based advice on how people can change behavior, sustain these changes, and enjoy the healthiest lifestyle possible.
