Signing up for an Aetna, UnitedHealthcare or Humana Medicare Advantage plan will always be a gamble. These health plans can save you money if you don’t need care, but if you need a hip replacement or any post-acute care services, you might find that they won’t pay for them. A new Office of Inspector General for the Department of Health and Human Services report finds that they deny coverage for costly post-acute care all the time, endangering the health and lives of their enrollees.
In an investigation of 2,000 prior authorization decisions in 2024, the OIG found that these corporate insurers–the big three that cover 20 million people with Medicare–had denial rates for critical post-acute care that reached as high as 80 percent. Most enrollees do not appeal these denials. But, those that did appeal ended up winning coverage the vast majority of the time.
According to the OIG, UnitedHealthcare overturned virtually all of its denials for nursing home admissions–99.7 percent–when enrollees appealed them. Aetna overturned 98.2 percent and Humana overturned 92.1 percent. But, fewer than one in five of their enrollees appealed.
The high overturn rates speak volumes about the impropriety of the denials. The insurers deny with impunity, knowing that the vast majority of people won’t appeal and that the government will not hold them accountable for their bad acts. It’s how corporate health insurers maximize profits, while causing emotional, physical and mental harm to their older and disabled enrollees.
In stark contrast, people in traditional Medicare experience few denials. Unlike the for-profit insurers that have a powerful financial incentive to deny care, the government rarely ever second-guesses people’s treating physicians. If the treating physician believes care is appropriate, traditional Medicare covers it.
In short, what most people don’t understand is that even though Medicare Advantage insurers must offer the same benefits as traditional Medicare, they refuse to cover many of the most costly services that traditional Medicare covers. It’s only when their enrollees appeal, do they admit that their denial was wrong and agree to cover the service.
Here’s more from Just Care:
- Adults in the commercial health insurance market report high rates of coverage denials
- OIG finds widespread inappropriate care denials in Medicare Advantage
- The many disadvantages of Medicare Advantage
- Medicare Advantage: Denials increase 56 percent
- Medicare Advantage insurers increasingly use step therapy for cancer drugs, delaying care
- Health systems are pulling out of Medicare Advantage in droves
