Concurrent review should follow the patient, not the setting. A Medicare Advantage enrollee who moves from a hospital bed to a skilled nursing facility can face a new review at the transfer. Another review may follow when home health care begins. Each review starts with a new request, and a new reviewer often reads it from a new packet of documents. The clinical story is the same patient’s, but the plan reads it as if for the first time.
Since January 2026, decisions MA plans make during a stay have been organization determinations. They carry the notice and appeal rights of any other determination. That change, from the CY2026 final rule, makes concurrent review a formal decision rather than an informal phone call. Plans should use it to review the episode as a whole, so a discharge does not wait on a review that could have started days earlier.
Every setting starts over
The cost of restarting shows up at the handoffs. A study in JAMA Internal Medicine, published in September 2025, analyzed more than 89 million hospitalizations from 2017 to 2023. Average stays for MA patients rose from 6 to 7.1 days, compared with 5.8 to 6.3 days in traditional Medicare, according to AHA News. The researchers pointed to prior authorization requirements and limited post-acute networks as possible causes. A patient who is ready to leave the hospital but waiting for a skilled nursing approval is a patient in the wrong bed.
Post-acute care is also where denials have grown. Our analysis of post-acute utilization management described a Senate investigation that found sharp increases in post-acute denial rates at large MA insurers. Each of those decisions was made at a transition, usually on documents assembled for that transition alone.
The rules already point toward continuity. When a plan approves a course of treatment, 42 CFR § 422.112 says the approval “must be valid for as long as medically necessary to avoid disruptions in care,” as our piece on approvals that last the course explained. The principle is that a decision should match the shape of the care. An episode that crosses 3 settings is a single course of care, even when it involves 3 benefits.
Review the episode
An episode review would change 4 things about how plans handle transitions.
- Start the next review before the transition. When a hospitalized patient is likely to need skilled nursing care, the plan opens that review during the hospital stay. The discharge planner and the plan work from the same timeline, so the approval is ready when the patient is.
- Carry the record forward. The episode file holds what the plan has already reviewed, including the hospital course and the reasons for earlier decisions. The next reviewer starts from that file instead of a new packet, and asks only for what has changed.
- Set the next review by milestone, not by calendar. A skilled nursing approval tied to the goals in the care plan is reviewed when those goals are met or missed. A fixed number of days invites a termination notice that has nothing to do with the patient’s progress.
- Keep a clinician on every no. An automated system can approve a continuation when the record supports it. A decision to end services needs a clinician who has read the current record.
The last point is already CMS policy. In its February 2024 answers on the CY2024 rule, CMS said a plan may use tools that predict how long a patient will need care, but “that prediction alone cannot be used as the basis to terminate post-acute care services.” Before ending services, the plan must show that the patient no longer meets the level of care requirements. It must also “base the decision on the individual patient’s circumstances.”
A patient who is ready to leave but waiting for an approval is a patient in the wrong bed.
The CY2026 change gives an episode review force. Because a decision during the stay is an organization determination, a downgrade or a termination carries notice and appeal rights at the moment it happens. Our analysis of the two-midnight rule in MA described what that means for inpatient status. The same logic applies at every transition. A plan that reviews the episode can make fewer of those decisions, and better ones, because it is not starting from zero each time.
What it would take
Episode review asks plans to break down their own walls. Many MA plans route hospital review and post-acute review through different teams, and some delegate post-acute review to outside vendors. An episode file has to cross those boundaries, which means shared records and shared accountability for the timeline.
It also asks something of providers. Hospitals would need to share discharge planning information earlier, and post-acute facilities would need to accept a review record they did not create. Privacy rules still apply. The episode file should carry what the next reviewer needs to decide, not the entire chart.
There are cases where a fresh look is right. A patient whose condition changes sharply between settings may need a new assessment, and carrying forward an outdated picture would be worse than starting over. Episode review is a default, not a rule against new information.
Where Redlake stands
Redlake builds tools that health plans use in utilization review. Our first rule is that a machine can say yes, but only a person can say no. Our second is that every recommendation shows its reasons. In an episode review, approvals for continued care can move quickly. A decision to end care goes to a clinician who sees the whole episode, with its reasons stated against the patient’s current record.
Our third rule is that every decision can be reconstructed. For an episode, that means a plan should be able to show the full sequence of decisions, from admission to the last home health visit, with what each reviewer knew at the time. A record like that serves the patient during the episode and the plan after it, when someone asks why a transition took as long as it did.