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Thursday, October 24, 2024

Medicare Advantage Scrutiny Continues - Part 5

The privatized Medicare plans, known as Medicare Advantage plans (such as the one offered by UC to retirees through UnitedHeathcare), continue to receive adverse publicity, including from a US Senate investigation. (We noted this issue in an earlier posting this week.)

From Fierce Healthcare:

The country’s three largest Medicare Advantage (MA) insurers obstruct seniors’ ability to receive post-acute care, a scathing report from the U.S. Senate Permanent Subcommittee on Investigations shows.*

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*NOTE: You can find the Senate report at

https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf.

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Between 2019 and 2022, the three insurers denied claims for post-acute care at “far higher” rates than for other types of care, and, in 2022, Humana denials in post-acute care were 16 times higher than the companies’ overall denial rates, the report (PDF) says. UnitedHealthcare and CVS denials were three times higher in the same year.

“Insurance companies say that prior authorization is meant to prevent unnecessary medical services,” said Sen. Richard Blumenthal, D-Connecticut, in a statement. “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. Our subcommittee even found evidence of insurers expanding this practice in recent years.”

The committee began the investigation in May 2023 and analyzed more than 280,000 pages of internal documents. The report was produced by Blumenthal’s staff. It reveals the insurers adopted new automated processes to speed up claims decisions, and, simultaneously, denials often increased.

The subcommittee is calling on the Centers for Medicare & Medicaid Services (CMS) to collect prior authorization data by service category and conduct audits when denial rates spike in certain areas. They also want more regulation around insurers’ internal prior authorization committees, because even if AI is only used to approve requests, medical professionals may be facing pressure to go along with AI recommendations in the name of efficiency and cost-cutting.

It outlines attempts from UnitedHealthcare, CVS and Humana—which collectively cover nearly 60% of all MA enrollees—to use technology to reject prior authorization claims, all while reaping profit.

Between 2019 and 2022, the three insurers denied claims for post-acute care at “far higher” rates than for other types of care, and, in 2022, Humana denials in post-acute care were 16 times higher than the companies’ overall denial rates, the report (PDF) says. UnitedHealthcare and CVS denials were three times higher in the same year.

“Insurance companies say that prior authorization is meant to prevent unnecessary medical services,” said Sen. Richard Blumenthal, D-Connecticut, in a statement. “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. Our subcommittee even found evidence of insurers expanding this practice in recent years.”

The committee began the investigation in May 2023 and analyzed more than 280,000 pages of internal documents. The report was produced by Blumenthal’s staff. It reveals the insurers adopted new automated processes to speed up claims decisions, and, simultaneously, denials often increased.

The subcommittee is calling on the Centers for Medicare & Medicaid Services (CMS) to collect prior authorization data by service category and conduct audits when denial rates spike in certain areas. They also want more regulation around insurers’ internal prior authorization committees, because even if AI is only used to approve requests, medical professionals may be facing pressure to go along with AI recommendations in the name of efficiency and cost-cutting...


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The publication Stat includes this chart about denials from UnitedHealthcare and two others. Note that the more severe case denials (Post-Acute Care - PAC) have risen substantially for UnitedHealthcare:

Put another way, if you are basing your evaluation on personal experience in earlier years, you may be underestimating the current practice.


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We're getting into Open Enrollment season, so for eligible retirees, we have this advice:


Good Luck!

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