A Senate subcommittee recently blasted Medicare Advantage plans for their handling of pre-authorization requests for post-acute care. The report, from the Senate Permanent Subcommittee on Investigation and released on October 17, focuses on the post-acute skilled nursing care that seniors frequently need to recover from illness or injury following a hospital stay.
Over half of Medicare eligibles are enrolled in Medicare Advantage plans (Part C). These are private plans that contract with the government to provide Medicare A and B services. They often provide extras such as vision care, prescription care without the need for Medicare D, etc. Premiums tend to be lower than for traditional Medicare, but subscribers face more preauthorization requirements and a more limited choice of health care providers.
Post-Acute Care Denials
The report, Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care, analyzed preauthorization data from the years 2019 through 2022 for the three biggest Advantage plans: Humana, CVS and United Health. It found that the rate of denials for post-acute care, an extremely costly service, was far greater than for other types of care. In 2022, both United Health Care and CVS denied prior authorization requests for post-acute care three times more often that for other types of services; Humana, sixteen times more often. In 2022, United Health Care’s denial rate for post-acute care was 22.7%, for Humana, 24.6%; and for CVS, 25.9%.
The report also criticized the plans’ increasing use of artificial intelligence tools to make decisions, alleging this cost-cutting tool results in more denials of medically necessary services for seniors, or early curtailment of post-acute services that sends seniors home before it is safe for them to go home.
Committee member Richard Blumenthal (D-Conn) states: “Insurance companies say that prior authorization is meant to prevent unnecessary medical services. But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions. In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors—simply to make more money.” Chip Kahn, CEO of the Federation of American Hospitals, agrees, stating: “The report today puts an exclamation point on what we’ve been saying for a long time: patients are being hung out to dry by MA plans’ delays and denials. It’s past time that legislators and regulators hold plans accountable and protect patient care.”
The committee calls for more scrutiny and regulation. For example, the report recommends that the Centers for Medicare and Medicaid Services expand audits. It also says steps are needed to ensure that “predictive technology” (i.e., algorithms and artificial intelligence) does not unduly influence human reviewers.
Naturally, Medicare Advantage insurers have not taken the report laying down. They point out that preauthorization protocols are already heavily regulated and monitored by the Centers for Medicare and Medicaid Services. Phillip Blando of CVS comments: “We provided extensive feedback to the committee on these errors, which unfortunately were not addressed in the final report.” Kevin Smith, a spokesperson for Humana, calls the committee’s findings a “partisan report laden with errors and misleading claims.”
What To Do If You Are Denied Post-Acute Care By Your Medicare Advantage Plan
If your Medicare Advantage insurer denies your preauthorization request for post-acute care, or cuts short the amount of time it will cover it, you may appeal the decision. There is a significant chance the appeal will be successful. Even so, those already recovering in skilled nursing settings tend not to appeal and just leave the facility, for fear they will get stuck with the cost if their appeal is ultimately denied.
The Centers for Medicare and Medicaid Services offers a summary of the steps to follow in the appeals process. Read it here.
You may get further assistance through the State Health Insurance Assistance Program (SHIP). A list of SHIP counseling resources in Florida can be accessed here.
If you are a patient who cannot handle the appeal process on your own, you may appoint a trusted person to handle the job on your behalf. To do this, you must appoint a representative using a special form available from CMS. Access the form here.
