A new investigation by Bob Herman and Casey Ross, reported in Stat News, reveals that UnitedHealth, Humana and other insurers are using algorithms to deny critical rehabilitation care to people in Medicare Advantage plans, in violation of Medicare rules and endangering their members. (You can bet real money that people needing all kinds of costly care are facing wrongful denials.) The report explains that these insurers are using A.I. software to keep people in critical condition from getting the medically necessary rehab services that people with Medicare get in Traditional Medicare and that the government pays these insurers to provide their enrollees.
UnitedHealth pushed its staff to adhere to the treating decisions of its NaviHealth software, without regard to the specific needs of rehab patients, endangering their health and well-being. Through these denials, UnitedHealth can keep more of the money that the government gives them to provide care. Not surprisingly, United’s NaviHealth software severely restricts or withholds needed care.
NaviHealth staff were fired or quit when they could not tolerate the medical decisions UnitedHealth was pressuring them to make based virtually exclusively on its NaviHealth software. UnitedHealth continues to claim that it is giving its members all the care they need.
Senior former officials at Medicare designed the NaviHealth product, which boosts UnitedHealth’s revenue by hundreds of millions of dollars a year. The Centers for Medicare and Medicaid Services, which oversees Medicare, is investigating, but it is clear that it lacks the resources and the power to hold the large insurers offering Medicare Advantage plans to account. It never has. President Biden needs to step in with an Executive Order.
Advocates are pressuring members of Congress and the administration to stop these insurers from enrolling new members and, at the very least, to warn enrollees about the risks to their health if they are enrolled in Medicare Advantage plans offered by these insurers. To date, CMS has done little. In fact, the information it provides on Medicare options is extremely misleading, steering people to Medicare Advantage plans that could endanger their health. Several members of Congress, including Mark Pocan, Katie Porter, Pramila Jayapal, and Jan Schakowsky, have sent letters to CMS asking it to hold the insurers to account.
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans
- If you want easy health care access and good quality care, you probably want traditional Medicare
- Government overpayments to Medicare Advantage plans grow, while concerns remain about quality of care
- 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
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