Providers should document medical necessity rigorously, as these algorithmically driven denials are frequently overturned on appeal.
UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients’ rehab care
The nation’s largest health insurance company pressured its medical staff to cut off payments for seriously ill patients in lockstep with a computer algorithm’s calculations, denying rehabilitation care for older and disabled Americans as profits soared, a STAT investigation has found. UnitedHealth Group has repeatedly said its algorithm, which predicts how long patients will need to stay in rehab, is merely a guidepost for their recoveries. But inside the company, managers delivered a much different message: that the algorithm was to be followed precisely so payment could be cut off by the date it predicted. Internal documents show that a UnitedHealth subsidiary called NaviHealth set a target for 2023 to keep rehab stays of patients in Medicare Advantage plans within 1% of the days projected by the algorithm.
— STAT News, November 14, 2023
Ross, Casey and Bob Herman. “UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients’ rehab care.” STAT News, 14 Nov. 2023. https://www.statnews.com/2023/11/14/unitedhealth-algorithm-medicare-advantage-investigation/.
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
