Failure to Obtain Proper Authorization for Medicare Advantage Disenrollment
Penalty
Summary
The facility failed to properly exercise the rights of three residents with dementia who had designated representatives by disenrolling them from their Medicare Advantage coverage without proper authorization or documentation. Facility policy states that residents have the right to choose their own healthcare insurance coverage and that only the beneficiary or their authorized representative can request enrollment or disenrollment from a Medicare plan. Written authorization is required for the facility to act on behalf of the resident in these matters. Resident records showed that all three residents had cognitive impairments and had designated responsible parties or legal representatives, such as a spouse, daughter, or guardian, to make healthcare decisions. Despite this, the facility changed the residents' primary payor from their Medicare Advantage plans to Medicare A without documented consent from the residents' representatives. There was no evidence in the clinical records or electronic medical records of completed disenrollment request forms or documentation of conversations with the families regarding the insurance changes. Interviews confirmed that the responsible parties were not notified or consulted prior to the insurance changes. One spouse reported not being contacted about the change, resulting in loss of coverage and subsequent billing issues. The Business Office Manager acknowledged that there was no documentation of family notification or completed disenrollment forms for any of the affected residents, despite facility policy requiring such actions when residents have cognitive impairment.