I’m an RN working as a Payor Relations Specialist in an LTACH, and I’m running into a consistent wall with Aetna Medicare plans.
We’re seeing extremely high denial rates for LTACH admissions, almost always citing “not medically necessary” or “can be managed at a lower level of care” (SNF, etc.), even in patients who are clearly high acuity (vent weaning, complex wounds, frequent monitoring needs, etc.).
For those of you who deal with this regularly:
• What specific clinical criteria or documentation have you found actually moves the needle with Aetna Medicare?• Are there particular phrases, benchmarks, or risk factors that seem to get approvals vs denials?• Have you had better success at peer-to-peer, and if so, what arguments tend to land?• Are you seeing the same trend, or is this more region/facility-specific?
I’m not looking for general “document better” advice — I’m trying to figure out what actually works in practice.
Appreciate any real-world insight.