TABLE 3.

MA Influence of SNF Length of Stay

Theme	Participant	Quote
Authorization-based approach	Administrator, Northeast (site 6, SNF 3, interview 1)	Managed care dictates the wow, okay, let me rephrase that, be careful, okay when we are confidential, um, they strongly suggest the discharge date based on diagnosis, and so if we think they need 3 weeks, they might only authorize 7 days at a time.
	Admissions coordinator, Southwest (site 1, SNF 2, interview 3)	Usually they have an estimated amount of time and then as we weekly, or whatever, send them all the faxes of the updates, how the patient’s doing in therapy, sometimes they’ll change that. They’ll authorize a certain amount of time and then say they authorize 2 weeks—and then, as it gets closer to that 2-week mark, they may extend that if they feel. But it’s all their decision. The managed cares [sic] decide when the patient is ready to go.
SNF response	Director of nursing, Northwest (site 5, SNF 4, interview 2)	My difficulties with managed care is [sic] they want the person out and they don’t want them better.... So even if we say, like we need more time, we need another 5 days, they’re pushing, pushing, pushing to get them out, because they’re getting reimbursed from Medicare so they want them out as fast as possible… I kind of feel like I’m working against managed care, where [with] people that just have basic Medicare, we don’t have that issue.
	Administrator, Northwest (site 5, SNF 4, interview 1)	There’s a lot of up-front requirements that are honestly set up so that if we fail to meet one of those requirements, they don’t have to pay. I mean essentially, it’s very strict on the up front trying to get authorization and then if you’re late by 1 day, they’re not paying the entire stay.
	Administrator, Southwest (site 1, SNF 3, interview 4)	They’re one of [the] lowest payers. So even if everything works great, quite honestly, we learned it’s not profitable. But when it’s only [a] 3-to-6-day length of stay, there’s so much work we actually do up front between admission and everything else associated with it, and then all of a sudden, you’re turning around and discharging them and then my guess is we’ve had 20, 25 percent of the families appeal [for a longer stay]. So then we’re having to put in a lot of hours just collecting all the paperwork to address the appeals. But at some point, it just becomes, you know, it’s not worth it.
	Administrator, Midwest (site 3, SNF 1, interview 3)	[Plan A] entered the market and is extremely unliked in [state] because they were auditing every single claim initially, which is ridiculous. Now they’ve agreed to reduce the amount of audits, but they are very challenging to work with in that they cut the people off really quickly. And we are often appealing on behalf of the patient.… So they’re a very high-maintenance [plan] and some [SNFs] won’t take ‘em anymore because of that.
Engaged approach	Admissions coordinator, Southeast (site 2, SNF 2, interview 2)	In the [SNF] they have nurses. Each managed care hires their own. And they come in and visit with the patients and our nursing staff…I think they’re here probably at least 2 to 3 times a week, you know depending on what your caseload is.
	CMO, Southwest (site 1, plan 1, interview 1)	What we do is we meet and greet patients, explain our role, which is mainly we assist the case manager in the facility.... I go over benefits with families, basically explain the plan of care and the anticipated length of stay at the facility. I’m there for any questions that my case managers might have.
SNF response	Administrator, Northwest (site 5, SNF 2, interview 1)	The contract process isn’t bad, and then once we’re in, we’re finding obviously that they want shorter lengths of stay.… We have some that we call the same person every week to give them updates, and things happen and say somebody changes their insurance midway through their stay and they don’t tell us? It’s nice to have that person that we can call and trust and say here’s what happened, can you help us out? And usually they can.… But it’s a headache to every week send in all the paperwork and get it approved. It’s just the nature of the game.
	Administrator, South (site 7, SNF 1, interview 1)	We have a managed care coordinator who actually spends most of her day talking to the managed care companies directly and she’s built a really great rapport with most of them…because sometimes it’s difficult to actually get a person when you’re dealing with managed care companies [laughing]. You get a number, a line, but she’s developed those direct contacts which makes this a lot easier to negotiate contracts and get authorizations approved as well.
	Director of nursing, Northwest (site 5, SNF 4, interview 2)	We have an HMO coordinator here. She does the updates. She kind of organizes, faxes, you know. Kind of does that communication between.… A lot of times if the family doesn’t agree [with the plan’s length of stay determination] or we don’t agree, we can give them the option of an appeal. Sometimes they win, sometimes they don’t. And there’s with one company we usually win all the time. And then with [other plan] we don’t. So they are very tight. I understand their points, but they don’t take our points into consideration.

CMO indicates chief medical officer; HMO, health maintenance organization; MA, Medicare Advantage; SNF, skilled nursing facility.