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Session 53 | Keeping Up with Managed Care: 2024 Wrap-Up, 2025 Changes, and What’s Ahead for 2026

Session Summary

Effective January 1, 2025, the CY 2025 Medicare Advantage (MA) final rule introduces significant reforms to the appeals process, empowering skilled nursing centers to challenge managed care denials more effectively. This rule establishes a more transparent system, granting centers access to independent reviews and the ability to escalate cases to an Administrative Law Judge (ALJ) when necessary. For years, centers have struggled with an appeals process dominated by insurers, often leading to unjustified denials and financial strain. These new protections offer fairer reimbursement opportunities and a structured path to advocate for appropriate care. With these policy shifts, centers now have the tools to combat improper denials, ensure fair reimbursement, and protect beneficiary care. In this session, attendees will learn how to navigate these critical changes and advocate effectively for their center and residents.

Presenters

Maureen McCarthy

Founder/CEO | Celtic Consulting

About the Presenter

Maureen McCarthy is the Founder and CEO of Celtic Consulting, a post-acute care advisory firm, and CEO of MDSRescue, providing remote MDS support nationwide. With nearly 40 years of experience, including roles as an MDS Coordinator, Director of Nursing, Rehab Director, and Medicare biller, she blends clinical expertise with regulatory insight to help clients develop sustainable remediation strategies. Maureen also holds key advisory and leadership roles across multiple national and state healthcare organizations.