JustCare

Tag: Appeal

  • Does UnitedHealth use flawed AI to deny care in Medicare Advantage?

    Does UnitedHealth use flawed AI to deny care in Medicare Advantage?

    Bob Hermann reports for StatNews that a case against UnitedHealth for using flawed AI algorithms to deny care to Medicare Advantage enrollees is making it way through the US District Court in Minnesota. (A similar suit has been filed against Humana, which uses the same AI system as UnitedHealth.) Will the judge agree that the artificial intelligence (AI) system is flawed and remedy the issue? First, the judge must find he has the authority to rule on this issue.

    UnitedHealth has moved to dismiss the case on the ground that plaintiffs have not worked their way through the lengthy appeals process and that federal Medicare law preempts state law. The judge will decide on that motion as early as this month. But, the stories of enrollees denied basic critical care by UnitedHealth abound. One older man, Frank Perry, needed rehab care to regain his strength after a brain disorder that caused him to fall a lot and landed him in the hospital each time. He couldn’t get it.

    UnitedHealth would only approve skilled nursing home care for Perry. Skilled nursing care is less costly than rehab care. Moreover, UnitedHealth only approved nursing care for two weeks, even though Medicare covers this care for up to 100 days when medically reasonable and necessary. Perry kept challenging the denials but he ended up dying before resolution of his case.

    UnitedHealth says it does not rely exclusively on AI to deny care. But, Stat got hold of UnitedHealth materials that run contrary to UnitedHealth’s claim. For sure, people who appeal win, more than four out of five times, suggesting that many denials are inappropriate. Unfortunately, most people don’t know to appeal or how easy it is to do so.

    Keep in mind that people enrolled in traditional Medicare do not face these barriers to care. As a general rule, they get the care they need when they need it.

    Here’s more from Just Care:

  • Oncologists report excessive deaths from prior authorization

    Oncologists report excessive deaths from prior authorization

    A new survey from the American Society of Radiation Oncology illustrates the dangers of prior authorization. Prior authorization kills an “inordinate number” of people and harms others. Insurers often deny care to the detriment of patients when physicians first ask for authorization; when denials are appealed, insurers then approve care the vast majority of the time.

    About 225 of the 750 radiation oncologists polled reported adverse health outcomes from prior authorization.  Their patients ended up in the emergency room or hospitalized or with a permanent disability. One in fourteen of the oncologists polled said that one or more of their patients had died as a result of prior authorization.

    Prior authorization can have benefits, particularly in cases in which physicians are not well trained. Prior authorization can ensure physicians are treating patients appropriately, based on evidence. Prior authorization can also keep costs down.

    But, insurers use prior authorization without regard to its effects on quality of life for patients. And, while prior authorization can help protect against unnecessary treatment, there is no one protecting patients from insurers that use prior authorization inappropriately, in ways that harm patients.

    The oncologists polled suggested insurers’ use of prior authorization is only increasing. Moreover, it increases staff burnout.

    • More than nine in ten oncologists (92 percent) reported treatment delays from prior authorization and nearly seven in ten (68 percent) reported delays of at least 5 days;
    • More than eight in ten oncologists (82 percent) blamed prior authorization for patients receiving less than the best care;
    • Nearly six in ten (58 percent) oncologists said prior authorization kept them from following recommended guidelines;

    Those polled made clear that it’s critical to appeal prior authorization denials because more than 70 percent are reversed on appeal. But, patients and physicians sometimes do not have the resources to appeal. In some instances, the tradeoffs of appealing care denials, in terms of time spent, means physicians are unable to do their jobs.

    Moreover, insurers still have 72 hours to review an expedited appeal. For some patients with health insurance, the harm from such a delay is significant.  One doctor said that in that time, “I’ve had patients who’ve literally had a tumor growing out of their chest. Waiting 3 days for an appeal means there’s more cancer to treat, even just in the time between when I made the plan for them initially, and when I actually get to start their treatment. Sometimes it means the plan has to change because the tumor has gotten that much bigger in that time period. Every day matters.”

    Insurers shouldn’t be allowed to continue doing prior authorization for treatments that are virtually always approved on appeal.

    Here’s more from Just Care:

  • Senate investigation shows high Medicare Advantage denial rates for costly care

    Senate investigation shows high Medicare Advantage denial rates for costly care

    One thing’s for sure. If there’s a way for the UnitedHealth, Humana and CVS/Aetna to profit off of Medicare Advantage, they will find it. We know that they overcharge the government more than $2,300 a year per enrollee. A new Senate Permanent Committee on Investigations report finds that Medicare Advantage insurers also profit from denying rehab services, nursing services and other costly services at ever-increasing rates.

    The Senate Permanent Subcommittee on Investigations’ report warns that insurers “are using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices.”  Older adults and people with disabilities are getting hurt. What exactly are the insurers doing to manage their enrollees’ care?

    According to Senator Richard Blumenthal, who chairs the Subcommittee: “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. Our Subcommittee even found evidence of insurers expanding this practice in recent years.”

    How do the insurers get away with all these denials? The report does not explain how the insurers get away with all these denials. But, the answer is simple. They often deploy a proprietary “secret sauce” to determine whether they should cover costly care. Their sauce can take a very narrow view of what is medically necessary care. Consequently, amputees can be denied rehab services. Newly diagnosed leukemia patients can be forced to wait long periods before their urgently needed care is approved.

    Is there evidence that insurers are not using prior authorization to improve care? All we hear is that they use prior authorization to keep people from getting care and to increase their profits. The Senate report does not get into other findings that some prior authorization denials for costly services are overturned on appeal more than 75 percent of the time. But, most people don’t appeal their coverage denials. The vast majority end up going without needed care. No one is looking out for them.

    The Centers for Medicare and Medicaid Services does not begin to have the resources to oversee nearly 4,000 different Medicare Advantage plans. It also lacks the power to hold insurers to account for their bad acts in meaningful ways.

    How to fix prior authorization? More rules won’t fix prior authorization in Medicare Advantage. Congress needs to take prior authorization out of the hands of the profit-driven insurers and put it into the hands of an outside independent entity that applies medically sound prior authorization rules in a standardized way across all Medicare Advantage plans.

    Here’s more from Just Care:

  • UnitedHealth claims enrollees cannot challenge inappropriate care denials in court

    UnitedHealth claims enrollees cannot challenge inappropriate care denials in court

    Several months ago, Stat News exposed a common practice at UnitedHealth care and other big insurers: Large numbers of Medicare coverage denials through the use of AI. Bob Herman now reports for StatNews that UnitedHealth care claims a judge should dismiss a class action lawsuit against it because enrollees did not exhaust administrative remedies for appealing denials.

    UnitedHealth is able to deny people coverage in Medicare Advantage with impunity and profit from its failure to comply with Medicare coverage rules. It knows that only a small fraction of people will appeal denials, so it can save money by not paying for care. It also knows that the Centers for Medicare and Medicaid Services, which oversees Medicare, does not have the resources to adequately oversee MA plans or the power to impose meaningful penalties on insurers when they violate their contracts and deny care inappropriately.

    So UnitedHealth allegedly denied thousands of Medicare Advantage enrollees’ rehab therapy using an algorithm, without regard to the individual needs of its enrollees. And, now it’s claiming that their class action lawsuit against UnitedHealth for these denials should be dismissed because the vast majority did not exhaust their full appeal rights. (In addition, UnitedHealth claims that federal law protects insurers from these lawsuits; it argues that enrollees must sue the Department of Health and Human Services.)

    UnitedHealth blames the federal government for their enrollees’ plight, a novel. If the appeals process were swifter, UnitedHealth claims, plaintiffs would not be suing.

    The reality, of course, is that older vulnerable patients should not have to appeal inappropriate denials of necessary care; they should not face these denials. They wouldn’t have to if United considered their individual needs in making coverage determinations and put those above their shareholders’ needs. But, UnitedHealth’s shareholders’ needs appear to come first and that means Medicare Advantage enrollees might not get the Medicare benefits to which they are entitled.

    We will know soon whether the judge in the lawsuit agrees with UnitedHealth that plaintiffs claims should be dismissed because they did not exhaust their administrative remedies. Plaintiffs say that had they done so, they would have suffered irreparable harm. They needed care quickly and couldn’t afford to pay for it out of pocket.

    The government designed the Medicare Advantage program with a major payment system defect. It pays the insurers upfront to deliver Medicare benefits, and what the insurers don’t spend on care they largely get to keep. So, they have a powerful incentive to deny care inappropriately.

    Here’s more from Just Care:

  • Medicare Advantage enrollees denied post-acute care get better protections

    Medicare Advantage enrollees denied post-acute care get better protections

    The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, just issued a final rule designed to protect Medicare Advantage enrollees whose Medicare Advantage plans deny them needed care and help ensure providers are paid for the care they deliver. Josh Henreckson reports for McKnight’s on how the rule improves the process for appealing Medicare Advantage denials for rehab and skilled nursing services after hospitalization.

    So that you’re up to speed: Insurers selling Medicare Advantage plans have repeatedly been found to inappropriately delay and deny necessary skilled nursing and rehabilitation care post-hospitalization. People in traditional Medicare get this care. Medicare covers up to 100 days of skilled nursing and rehab services for people who need daily skilled services and have been hospitalized for at least three days in the 30 days prior to admission to a facility.

    People enrolled in Medicare Advantage plans struggle to get the rehab and skilled nursing care they need, not only because their plans deny them coverage but because they are on the hook for the cost of care that their Medicare Advantage plans won’t cover even when they appeal the decision. The CMS final rule ensures that these patients will not be liable for the cost of their treatment if they fail to appeal a denial of coverage while they are in the skilled nursing facility or rehab facility or if  they do not win their appeal. Beginning in June, people in MA plans whose post-acute care is terminated will no longer be liable for the full cost of services after termination.

    People who appeal these Medicare Advantage plan denials of skilled nursing or rehab care win more than eight in ten times. But the vast majority of people do not appeal. Often they do not know they can appeal. Or, they fear having to pay privately for the cost of their care if they do not win on appeal.

    As important, the new CMS rule requires that an independent organization decide fast appeals for people in skilled nursing and rehab facilities. The Quality Improvement Organization and not the Medicare Advantage plans will decide these appeals

    And, if people continue their care after their Medicare Advantage plan terminates their post-acute coverage and do not appeal at that time, they will now have the right to appeal after they leave the skilled nursing or rehab facility.

    The final rule also helps skilled nursing and rehab facilities. They have been struggling because Medicare Advantage plans fail to pay them even when these plans’ have inappropriately denied their patients needed care. Without an independent review agency, there’s no reason for providers to believe that care denials will be overturned; the insurers have no incentive to reverse their original decision.

    Here’s more from Just Care:

  • Office of Inspector General finds insurers inappropriately deny care to people with Medicaid

    Office of Inspector General finds insurers inappropriately deny care to people with Medicaid

    Healthcare Finance reports on new Office of Inspector General findings regarding high prior authorization denial rates in Medicaid managed care as well as a high likelihood that some people with Medicaid are not getting the care they need. The OIG urges the Centers for Medicare and Medicaid Services (CMS) to do more to ensure that the insurance companies offering managed care to people with Medicaid are honoring their obligations to cover needed care, rather than putting profits first by denying care inappropriately.

    The Office of the Inspector General is concerned that people with Medicaid are not getting needed care that corporate insurers should be covering. Moreover, there is little oversight of these corporate insurers. The Centers for Medicare and Medicaid Services and state insurance departments only conduct limited oversight of the insurance companies’ denials. And, people with Medicaid have restricted access to reviews of their denials. Even in Medicare Advantage, CMS oversight is extremely limited; CMS allows health insurers to deny care wrongly with near impunity.

    Medicaid insurance companies denied about 12 percent of prior authorization requests or about one in eight of them on average. But, ten percent of the managed care plans that the OIG reviewed denied one in four or more requests for prior authorization. People with Medicaid should know which plans have these high denial rates so they can avoid enrolling in them.

    The OIG fears that oversight bodies are not on top of many inappropriate denials of care. So, inappropriate denials continue because they are not addressed.

    In addition, the Medicaid appeals process in most states does not offer people the opportunity for an independent review of denials. So, the appeals process is not a check on most insurance companies offering Medicaid. People do have the right to fair hearings in their state, but the process can be challenging for people with Medicaid. Appealing to the Medicaid health plan directly is also not common.

    The OIG claims that the system is better for people in Medicare plans operated by insurance companies. That may be true, but the differences do not lead to particularly good outcomes for people with Medicare in these corporate managed care plans. The Centers for Medicare and Medicaid Services does little to hold Medicare Advantage plans accountable for their bad acts, even if these plans must report data on denials and appeals.

    If CMS reviews the appropriateness of Medicare Advantage prior authorization denials each year, it should report its findings. People should not be forced to choose a Medicare Advantage plan without knowing the risks that they will be denied care inappropriately if they enroll.

    Prior authorizations can be harmful to people’s health, often delaying critical care needlessly. More than nine in ten physicians report these delays. And one in three physicians say that prior authorization leads to serious harm to patients they care for. Nine percent of them say prior authorization leads to “permanent bodily damage, disability or death.”

    Here’s more from Just Care:

  • Medicare Advantage: Beware of inappropriate nursing home stay denials

    Medicare Advantage: Beware of inappropriate nursing home stay denials

    Susan Jaffe writes for Kaiser Health News about the risk that your Medicare Advantage plan will inappropriately deny you the nursing home care you need. Because the government pays Medicare Advantage plans a flat upfront fee, they have a powerful financial incentive to keep you from getting the costly care you need. They profit more the less they spend on your care.

    No one is monitoring in real time when and how Medicare Advantage plans delay and deny nursing home care, or any other care for that matter. The government pays Medicare Advantage plans to cover the same amount of medically necessary care as traditional Medicare covers. And, though the Medicare nursing home benefit is limited, it should cover as much as 100 days in a nursing home for people who have been hospitalized as an inpatient for at least three days in the 30 days prior to nursing home admission and who need daily skilled nursing or therapy services.

    The Office of the Inspector General (OIG) reports that Medicare Advantage plans can and do stint on costly care, including nursing home care, even when your treating physician says it is medically necessary. And, the Centers for Medicare and Medicaid Services (CMS), the agency charged with overseeing Medicare, does not publicly identify the bad Medicare Advantage actors, let alone cancel contracts with those that engage in widespread inappropriate delays and denials of coverage, as some do.

    In her story, Jaffe reports on a 97-year old woman in a nursing home whose Medicare Advantage plan told her it was ending nursing home coverage after only an 11-day stay. Her medical team disagreed with the decision, saying that she was not in good enough health to return home. She had taken a bad fall. Experts report that it has become increasingly common for Medicare Advantage plans to overrule the treatment preferences of patients and their doctors and deny care, without even seeing the patient.

    The American Health Care Association has “significant concerns” about the behavior of Medicare Advantage plans. No question that people are better off in their homes when they are healthy and able to take care of themselves, as the Medicare Advantage plans argue. But, it’s unsafe to push vulnerable older adults out of a nursing home before they are in good enough shape to manage at home.

    If your Medicare Advantage plan denies you skilled nursing facility or rehab care that your medical team says you need, you have the right to appeal. With a letter from the medical team explaining why care is medically reasonable and necessary and why you meet the eligibility requirements for skilled nursing facility or rehab benefits, there is a very high likelihood the Medicare Advantage plan will reverse its decision. And, if it does not do so, you can appeal to a higher level authority, where you are likely to succeed on appeal.

    There is no cost to appealing a Medicare Advantage denial of coverage, and it’s easy. You will likely face bills from the nursing facility while your appeal is being decided. But, you can ignore the bills if you win your appeal, and you have a high likelihood of winning. The Medicare Advantage plan will have to pay. Unfortunately, your Medicare Advantage plan faces no penalty for inappropriate denials. So, it can continue to deny care inappropriately without any likely consequence.

    Here’s more from Just Care:

  • Health care coverage denied? Appeal, it’s easy

    Health care coverage denied? Appeal, it’s easy

    In its infinite wisdom, Congress is eyeing a fix for people with poor health insurance whose health care is wrongly denied or delayed. No, it’s not guaranteeing everyone good health insurance. It’s not even ensuring that health insurers pay claims appropriately and in a timely manner. Rather, CNBC reports that some Democrats in Congress want to give people the right to sue their health insurance company.

    If you have Medicare, you already have the right to appeal denials of care. Most people don’t realize they can or that it’s worth the time, so only about 1 percent of people appeal. But, more than 75 percent of appeals result in coverage, according to the Office of the Inspector General. And, appealing a denial of care or coverage is easy and free. You don’t need a lawyer.

    To appeal, simply send a letter from your doctor justifying the need for a medical service to the address on your Explanation of Medicare Benefits form or your Medicare Advantage form and request the appeal.

    That said, if you want to sue your health insurance company in federal court because it denied your claim or it’s not paying your medical bills in a timely fashion, chances are you can’t. Some Democrats want to change that. 

    Health insurers generally write their contracts to require arbitration of coverage disputes. They prevent class action lawsuits. Arbitration protects health insurers because decisions are neither open to public scrutiny nor easy to appeal. Arbitration keeps the health insurers from being accountable for their bad acts.

    Congresswoman Katie Porter, D-Calif. proposes the Justice for Patients Act, which would prevent health insurers from requiring arbitration. It would allow individual and class action lawsuits if patients preferred to go that route.

    Lawsuits might help to hold health insurers accountable. Patients rarely win money in arbitration disputes, according to the Economic Policy Institute. Fewer than one in ten arbitration disputes lead to financial rewards for patients.

    So long as corporations can require consumers to engage in arbitration, they will. Porter’s bill focuses exclusively on permitting lawsuits against health insurers. But, arbitration is required in all kinds of discrimination, sexual harassment and civil rights cases. People should have the right to sue corporations. Corporations have little to fear if their behavior is not egregious. The costs are steep enough and the time involved prolonged enough that lawsuits will never become the first line of attack.

    Here’s more from Just Care:

  • Do you need care? Why should your health insurer decide

    Do you need care? Why should your health insurer decide

    In a Washington Post op-ed, William E. Bennett Jr., a gastroenterologist and associate professor of pediatrics at the Indiana University School of Medicine, makes the case that health insurers should not be allowed to practice medicine. They too often deny medically necessary care unless and until your doctor is willing to go through hoops with their medical staff. But, medical staff who work for health insurers have no clue whether you need care.

    Bennett appreciates our need for health insurance. He also recognizes that having health insurance is necessary but not sufficient for our well-being. To get his patients needed medicines and tests, he must request prior authorization from his patients’ insurers, which can needlessly delay their access to care for weeks. And, still, the insurers may deny needed care.

    Only if Bennett appeals to a doctor who works for the insurer and says the right key phrases, will the insurer reverse its denial. Most of the time, the doctor in the employ of the health insurer has little accurate information about the patient; the doctor has never had any contact with the patient. Bennet explains that the insurer’s doctor is unqualified to know whether the treatment or medicine is needed.

    There is nothing beneficial about this process for the doctor or the patient. It does not assure the patient gets the proper treatment. In fact, it keeps many patients from getting needed care. And, it burdens the doctor excessively and unreasonably.

    Bennett experiences the system from the patient’s side as well because his daughter has a serious health condition, and he has had to deal with an insurer that has limited her access to needed treatment. Appealing is a challenging process that requires Bennett to rely on the advocacy of his daughter’s doctors. It takes time and does not always work. In the meantime, his daughter suffers, even though his daughter’s treating physicians all know she would benefit from the treatment.

    In short, when health insurer denials are based on the insurer’s claim of lack of medical necessity, the system breaks down, and the most vulnerable patients are harmed. One study revealed that one health insurer denied claims for emergency visits that met a “prudent layperson” emergency coverage standard in more than 85 percent of cases. Patients can appeal the denials with a high likelihood of success on appeal. But, only a tiny number know they can appeal and have the wherewithal to do so.

    Bennet concludes that health insurers should not be able to decide the care people need: “When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.”

    Here’s more from Just Care:

  • Inappropriate Medicare Advantage care denials appear widespread

    Inappropriate Medicare Advantage care denials appear widespread

    A recent report from the HHS Office of the Inspector General (OIG) raises serious concerns about inappropriate Medicare Advantage denials of care as well as wrongful payment denials. It shows that Medicare Advantage plans, commercial health plans that contract with Medicare to deliver Medicare benefits, overturn their own denial decisions 75 percent of the time. Unfortunately, most people do not appeal their denials.

    The OIG report suggests that Medicare Advantage plans are likely inappropriately issuing denials many millions of times a year. The data show that only one percent of Medicare Advantage plan members appealed their denials between 2014 and 2016. And, even with such a small fraction of their members appealing, Medicare Advantage plans overturned 532,000 denials of care or payment–three out of four of these denials–over the two-year period.

    Put differently, 99 percent of Medicare Advantage plan members, who were denied access to care or payment for services they received, did not challenge their denials. They likely did not understand that they have a right to appeal or that it is an easy process. Had they appealed, there is good reason to believe that three out of four of them would have won their appeals.

    Centers for Medicare & Medicaid Services (CMS)  audits of Medicare Advantage plans support the OIG’s findings that many Medicare Advantage plan members may not be getting the care or coverage to which they are entitled. CMS has found profound and persisting problems with Medicare Advantage plans wrongly not paying for care or not approving care. In 2015 alone, CMS found that more than half of the Medicare Advantage plans they audited (56 percent) inappropriately denied care or payment.

    In addition, in its audits of Medicare Advantage plans, CMS found that more than four in 10 Medicare Advantage plans (45 percent) did not provide their members with appropriate or correct information about their denials, undermining their members’ ability to challenge them. CMS penalized these Medicare Advantage plans, but the punishment has not deterred them from continuing to wrongly issue denials.

    The OIG recommends that CMS take stronger action against Medicare Advantage plans. In addition, it notes that even when CMS audits show widespread wrongful denials by Medicare Advantage plans, they do not affect a Medicare Advantage plan’s star ratings. As a result, these star ratings have little if any value for individuals choosing among Medicare Advantage plans. Moreover, health plans that CMS sanctions can also receive quality bonus payments.

    Whenever you receive a denial from your Medicare Advantage plan, you should fight back. You have a high likelihood of winning. It’s a simple process and it’s free.

    If you are trying to evaluate differences among Medicare Advantage plans, do not rely on the star ratings. Avoid plans sanctioned by CMS, which is noted on the Medicare Plan Finder web site.

    Here’s more from Just Care: