The subcommittee’s recommendations for CMS to collect service-level prior authorization data and conduct targeted audits may increase scrutiny of MA denial practices.
Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care
“This Majority staff report reveals how Medicare Advantage insurers are intentionally using prior authorization to boost profits by targeting costly yet critical stays in post-acute care facilities. Insurer denials at these facilities, which help people recover from injuries and illnesses, can force seniors to make difficult choices about their health and finances in the vulnerable days after exiting a hospital.”
— U.S. Senate Permanent Subcommittee on Investigations, 17 Oct. 2024United States, Senate, Permanent Subcommittee on Investigations. Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care. U.S. Senate Committee on Homeland Security and Governmental Affairs, 17 Oct. 2024. https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf
Senate Report on Medicare Advantage Targets AI-Driven Denials by CVS, Humana and UnitedHealthcare
“The investigation highlights concerns about using machine learning models to forecast denial outcomes rather than conducting personalized medical necessity reviews. The practice raises questions about whether beneficiaries receive appropriate care decisions based on their specific circumstances.”
— Healthcare Dive, 21 Oct. 2024
Who’s Putting Profits Before Patients Now?
“By denying access to necessary post-acute care, they are forcing seniors and their families into impossible situations: either remain in a facility and shoulder crushing out-of-pocket costs or return home prematurely, where they may lack the support needed for a full recovery.”
— McKnight’s Long-Term Care News, 20 Oct. 2024
“In 2019, for instance, UnitedHealthcare issued an initial denial to 1.4% of requests for admission to skilled nursing facilities. But in 2022 — the first full year in which naviHealth was managing denials using its nH Predict tool — the insurer denied 12.6% of such requests, or nine times more than before.”
— McKnight’s Long-Term Care News, 18 Oct. 2024
“This report should concern all of us because at its heart is the outright denial of care to seniors when they needed post-acute care most. Insurers and artificial intelligence should not determine if or how long a senior needs skilled nursing facility recovery — that’s a decision for the patient and their care team.”
— American Health Care Association, 18 Oct. 2024
U.S. Senate Subcommittee Cites Serious Concerns on Medicare Advantage’s Denial of Post-Acute Care
“CVS reported saving over $660 million in one year by denying inpatient facility admissions. Humana modified denial templates to facilitate higher rejection rates.”
— Skilled Nursing News, 17 Oct. 2024
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