JustCare

Tag: Denial

  • 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:

  • Medicare Advantage inappropriate denials of care abound

    Medicare Advantage inappropriate denials of care abound

    Just as with restaurants, automobiles and homes, Medicare Advantage plans vary from awful to excellent. But, unlike with restaurants, automobiles and homes, you can’t choose a Medicare Advantage plan knowing it will meet you needs. It’s a total crapshoot. Inappropriate denials of care abound.

    Beware. And take a hard look at your Medicare Advantage plan, if you’re in one. Choosing the wrong Medicare Advantage plan could kill you. A report from a few years ago revealed that if the Centers for Medicare and Medicaid Services cancelled contracts with the five percent of worst performing Medicare Advantage plans, it would save tens of thousands of lives a year!

    To ensure you have access to the care you need when you develop a serious condition or suffer a bad injury, consider switching to traditional Medicare, the government administered program that covers your care from most physicians and hospitals anywhere in the US. You have until the end of March to switch. But, unless you have Medicaid, you will need to be sure you can buy supplemental coverage to fill gaps in traditional Medicare.

    If you stay in a Medicare Advantage plan, be prepared to fight your insurer when you need costly care. CMS not only does not cancel contracts of insurers with high rates of inappropriate denials, it doesn’t tell you which are the worst-performing Medicare Advantage plans.

    Do not assume that a Medicare Advantage plan with a five star rating will meet your needs. The ratings do not factor in inadequate networks or inappropriate denial rates, much less mortality rates. And, while CMS has worked to improve those ratings, the insurers have successfully sued to prevent changes to the ratings. For reasons yet unknown, the Trump administration just dropped a Biden administration appeal of one of those lawsuits.

    If you stay in Medicare Advantage, consider denial rates. The latest report from the Kaiser Family Foundation reveals that CVS and Centene have the highest prior authorization denial rates in 2023. On average, MA plans denied 6.4 percent of prior authorization requests, which might sound reasonable. But, MA insurers use prior authorization predominantly for costly services, which only a small fraction of their enrollees need.

    Centene’s denial rate was 13.6 percent in 2023. CVS Health’s was 11 percent. Typically, denials are overturned 80 percent of the time when appealed. When people appealed Centene’s denials, they prevailed 93.6 percent of the time. Unfortunately, only about 10 percent of coverage denials are appealed.

    Here’s more from Just Care:

  • Medicare Advantage insurers are killing rural hospitals and communities

    Medicare Advantage insurers are killing rural hospitals and communities

    Write-Off Warrior, a research and advocacy firm that supports rural health systems, just released “Preyed On: How Insurance Corporations are Bleeding Rural Hospitals and Communities to Death.” The report documents the many harmful behaviors of large insurance corporations responsible for endangering the health of rural America. The report also highlights the far-reaching consequences for our country if Congress fails to address insurer behaviors driving rural health disparities.

    Rural Americans represent about 20 percent of the US population. They tend to suffer more from chronic conditions than other Americans. But, they struggle more to get the care they need than other Americans and their plight is worsening.

    The authors surveyed 41 rural hospitals in 15 states across the US and found that the biggest problems they faced were burdensome insurer prior authorization procedures, insurers’ second-guessing of treating physicians, and insurers’ long delays and denials of provider payments. Moreover, insurers take advantage of rural hospitals’ weak bargaining power to negotiate excessively low rates or to keep these hospitals from being in-network. Rural hospitals are foundering.

    Medicare Advantage insurers are the biggest threat to rural hospitals and communities, according to 31 of 41 hospital execs surveyed. These corporate insurers have undermined the hospitals’ financial stability. These insurers have led rural hospitals to end important mental health and rehab services. And, these insurers are leading many rural hospitals to shut down altogether.

    While the top six Medicare Advantage insurers profited to the tune of $41.7 billion in 2023 alone, Medicare Advantage enrollees continue to face rising costs, notwithstanding these insurer practices. They also are often forced to travel long distances for care. Congress must recognize that Medicare Advantage does not work for rural Americans and reform the system.

    Until Congress reforms the Medicare Advantage program to meet the needs of rural Americans, insurers will profit more at the expense of rural communities. Nearly 200 rural hospitals have closed in the last 2o years. And, more than 700 are at serious risk. These hospital closures put rural America on life support.

    Without vibrant rural communities and good rural health, critical food and energy production, vital to the entire country, are at risk of failing.

    Here’s more from Just Care:

  • Will UnitedHealth stop denying care inappropriately or simply deny doing so?

    Will UnitedHealth stop denying care inappropriately or simply deny doing so?

    Shareholders at UnitedHealth are proposing that the company study and report publicly on the financial and public health consequences of its policies that lead to delays and denials of health care. These shareholders want people to vote on their request at UnitedHealth’s annual meeting, reports Rylee Wilson for Becker’s Payer.

    Specifically, the shareholders want UnitedHealth to report on the frequency of delays of care and foregone care, as well as harm to patients, resulting from UnitedHealth’s prior authorization requirements. Put differently, they want the company to disclose how its prior authorization requirements affect access to treatment.

    UnitedHealth claims it will respond to these shareholders once it schedules its annual meeting in June. The shareholders, represented by the Interfaith Center on Corporate Responsibility, represent more than 300 institutional investors. (UnitedHealth has more than 5,000 institutional investors.)

    The shareholders argue that these inappropriate delays and denials might boost short-term profits, but they risk hurting the UnitedHealth brand.

    Wendell Potter, head of the Center for Health and Democracy, explains that the inappropriate care denials harm more than patients. UnitedHealth defends its behavior saying that it pays 90 percent of claims, which might be true. The problem is that the 10 percent of claims it denies are often for coverage of expensive life-saving or otherwise critical care.

    Meanwhile, UnitedHealth is poised to announce big year-end profits. Some say UnitedHealth will have more than an eight percent year-over-year earnings growth. Fourth-quarter earnings are projected to be about $6.72 a share. If so, it would be a 9.1 percent increase from last year’s fourth quarter.

  • Some of UnitedHealth’s many abuses in a nutshell

    Some of UnitedHealth’s many abuses in a nutshell

    In a New York Times fluff piece, the head of the UnitedHealth Group, Andrew Witty, attempts to make the case that his company does not deserve to be maligned. (Here’s my letter to the New York Times in response. The American Economic Liberties Project has been tracking the publicly recorded illegal and wrngful conduct of UnitedHealth Group, including patient abuses, provider abuses and retail pharmacy abuses. UniteHealth Group (UHG) is the conglomerate that owns UnitedHealth insurance as well as more than 2,300 other companies. It is the biggest health care corporation in the country.

    The types of companies that UHG owns include pharmacies, health insurers, pharmacy benefit managers, primary care and mental health providers, surgery clinics, home health and hospice agencies. Optum, one of UHG’s subsidiaries, employs 90,000 physicians, more than any other company. It is also one of the three biggest PBMs, which design formularies for insurance companies, choosing the drugs and patient copays.

    UHG’s ownership of all these lines of business allows it to game the health care system in all sorts of ways to maximize profits and squeeze smaller companies out of business.

    What types of abuses has UHG subsidiaries been found to engage in?

    • Overcharging: The Medicare Payment Advisory Commission (MedPAC), the Committee for a Responsible Federal Budget (CRFB), and many other organizations have reported that each year UHG and other large insurers charge the government more than they should for the services they deliver. This year alone, overcharges amounted to somewhere between $83 billion and $140 billion. UHG has a history of upcoding–submitting medical codes to federal programs for more serious and more expensive diagnoses or procedures than what was necessary, diagnosed, or performed. As a result, UHG overbills the federal government, wasting billions in taxpayer dollars.
    • Denials of care: The data show that UHG denies one out of every three requests for coverage, keeping patients from getting the care they and their treating physicians believe they need. They overrule their own network physicians in order to spend less on care and maximize profits.
    • Anticompetitive behaviors: Because UHG owns so many health-related companies, it can and does steer patients and physicians to the products and services their companies deliver.
    • Patient privacy violations: UHG uses patient data without patient consent, violating patient privacy.

    Over the last seven year, UHG has been charged with engaging in these activities: 

    • Eight reports and three lawsuits for overcharging the federal government.
    • 10 reports and five lawsuits for denying patient care because of the cost rather than medical necessity.
    • Eight reports and seven lawsuits for steering patients and providers to companies that UHG owns.
    • Three reports of corrupt practices.
    • Two reports and one lawsuit for violating patient privacy.

    For more information on UHG abuses, visit violationtracker.org.

    Here’s more from Just Care:

  • Americans are extremely angry about US health care

    Americans are extremely angry about US health care

    The murder of UnitedHealthcare CEO, Brian Thompson, has revealed extraordinary anger among Americans over our health care system. Will Congress finally act to guarantee people access to needed care and prevent insurers from inappropriate delays and denials of care? Likely not.

    Tens of thousands of people on social media reacted unsympathetically to the killing. ““When you shoot one man in the street it’s murder,” one person posted on the social media site X. “When you kill thousands of people in hospitals by taking away their ability to get treatment you’re an entrepreneur.”

    Wendell Potter, a former Cigna exec and whistleblower, explains on CNN how the CEO’s murder happened just ahead of a shareholder and investor meeting of UnitedHealthcare. UnitedHealthcare satisfies its investors through restricting access to care. That’s how UnitedHealthcare maximizes profits.

    Potter explained that “There’s a lot of just pent-up outrage at this company and other companies that are middlemen that are standing between a patient and his or her doctor or hospital.” For their part, Minnesota physicians report excessively high denial rates by UnitedHealthcare.

    As a result of insurance company practices, people are not getting the medically necessary care they need. The casings on the bullet of the gunman who killed Thompson echo the practices of the insurers: “delay” and “deny.”

    According to the Minnesota Star Tribune, United Healthcare also has been accused of relying on a claims process, supported by artificial intelligence, that had a 90% error rate in determining whether a requested treatment was medically necessary.”

    The Star Tribune further reports on UnitedHealthcare’s insanely high denial rates. In 2021, “UnitedHealth’s qualified health plans in Arizona denied almost 39% of in-network claims.” UnitedHealthcare is the largest health insurer in the US. Another 16 smaller insurers had denial rates that were above 30%.

    Only a few days ago, Anthem decided not to go forward with a proposal to limit anesthesia coverage for certain surgeries and other procedures. It appeared to act in response to massive outrage at the policy. Had Anthem moved forward with the proposal, it would have driven up health care costs for Americans and maximized profits for the insurer.

    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:

  • It’s Medicare open enrollment season, here’s what to do and not do

    It’s Medicare open enrollment season, here’s what to do and not do

    During this Medicare Open Enrollment period between October 15 and December 7, here’s what to know:
    • People on limited incomes can’t make a meaningful Medicare choice.
    • Only Traditional (Original) Medicare gives you the freedom to receive the care you need from the doctors and hospitals of your choice. But it lacks an out-of-pocket cap, so it comes with financial risk unless you also have supplemental coverage, which can be expensive. 
    • Medicare Advantage is always a gamble. MA plans can overrule your doctor and deny you the care you need.
    If you can’t afford Traditional Medicare, call your member of Congress and tell them to add an out-of-pocket cap. 

    Whether you’re in Traditional Medicare or a Medicare Advantage plan, your Medicare Part B premiums will increase and your Part D prescription drug coverage will change in 2025. You should compare your prescription drug Part D options. And, you should be aware that sometimes it is less costly to get your drugs from Costco or another low-cost pharmacy than to get them through your Part D insurance.

    To ensure you get covered for the care you need from the doctors and hospitals you want to use, without administrative hurdles, make sure you are enrolled in Traditional Medicare, the government-administered Medicare program.Only Traditional Medicare gives you the freedom to receive the care you need from the doctors and hospitals of your choice. Unlike Medicare Advantage, Traditional Medicare allows you and your treating physician to decide the care you need without second-guessing. And, with supplemental insurance you have few if any out of pocket costs. But because TM lacks an out-of-pocket cap, millions of Americans can’t afford it.

    If you cannot afford Traditional Medicare or you cannot get supplemental coverage to fill coverage gaps, you have no choice but to enroll in Medicare Advantage. Medicare Advantage is always a gamble. You cannot make a meaningful choice of a Medicare Advantage plan. MA plans can overrule your doctor and deny you the care you need. Reports show widespread and persistent delays and denials of care and coverage in many MA plans. You cannot avoid that. The best you can do is pick a plan with a five-star rating and hope you don’t get sick.

    Don’t assume that anything about your Medicare Advantage plan will remain the same in 2025. Your physicians and hospitals could be leaving the network. Your costs could be rising. Your prescription drug coverage could be changing. Review all your Medicare options carefully, including Traditional Medicare.

    How to choose a Medicare Advantage plan? You can’t make an informed choice or avoid bad actor MA plans.You can’t know in advance whether an MA plan is engaged in widespread and persistent inappropriate delays and denials of care, as many of them are. The government cannot protect you from Medicare Advantage bad actors that do not cover your Medicare benefits, as required. The best you can do is pick a plan with doctors and hospitals you want to use in its network and hope they don’t leave. You can’t count on them staying. This year alone, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care. Unfortunately, in Medicare Advantage, you are gambling with your health care and could incur thousands of dollars in out-of-pocket costs. Insurers have a financial incentive to deny care; the less care they cover, the more they profit. Don’t be seduced by “extra” benefits, which are often very limited and can come with high out-of-pocket costs.

    Keep in mind that when you need costly and complex care, your Medicare Advantage plan is likely to require prior authorization and could overrule your treating physician, denying you coverage. You can appeal, but you might need to pay out of pocket for the full cost of your care. Even when Medicare Advantage plans approve your care, they generally force you to go through hoops and face delays before they will cover your care.

    Don’t trust an insurance agent’s advice about your Medicare options. Unfortunately, insurance agents are paid handsomely to steer you away from Traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. You can’t know whether you can trust an insurance agent.

     If you have Medicare and Medicaid:

    • You will have much easier access to physicians and inpatient services in Traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition. And, you will have no out of pocket costs.

    For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).

    Here’s more from Just Care:

  • Doctors and hospitals face increasing claims denials

    Doctors and hospitals face increasing claims denials

    The big health insurers are destroying our health care system, while profiting wildly. They cannot rein in costs, so Americans with insurance often cannot afford their care. Moreover, the insurers don’t appropriately reimburse physicians and hospitals for the services they deliver. Jeff Lagasse reports for Healthcare Finance on a new report revealing the increasing rate of claims denials health care providers are facing.

    In his review of The State of Claims 2024 report by Experian, Lagasse points out that providers do not have the technology to contest insurers’ claim denials efficiently. The report also focuses heavily on provider concerns about insurer preauthorization rules and policy changes that prevent them from getting paid appropriately.

    Our government allows corporate health insurers to hold all the cards. They decide what health care services to pay for and when, second-guessing treating physicians on what services are medically necessary. And, they are rarely accountable for failing to cover services they are supposed to cover or for delaying payment. Rather, they are accountable to Wall Street to increase profits, which creates a powerful incentive for them to deny and delay care and provider reimbursements.

    Policy changes, claims denials and payment delays are three ways insurers are increasingly profiting at the expense of providers:

    • 77 of providers say that insurer policy changes are occurring more frequently.
    • 73 percent say that insurers are denying claims more frequently.
    • 67 percent say that insurers are delaying payment more often.

    Nearly four in ten providers (38 percent) say that insurers are denying claims ten percent of the time or more. More than a third of the time, insurers refuse to authorize care. The rest of the time, insurers claim that data is missing from provider claims.

    The rate of Medicare Advantage denials is increasing with each passing year. The Kaiser Family Foundation recently reported that in 2022, Medicare Advantage insurers denied 7.4 percent of prior authorization requests, up from 5.8 percent in 2021 and 5.6 percent in 2020. It’s no wonder that this year alone more than 24 health systems have cancelled their Medicare Advantage contracts.

    Lagasse cites a 2017 report revealing that health care organizations several years ago lost $262 billion on claim denials out of $3 trillion in claims submitted, in a single year. After appealing, at a cost of $8.3 billion, the providers recouped 63 percent of that money. Insanity.

    Maybe AI can deliver greater efficiencies for health care providers and increase their revenues, as some suggest. But, you have to imagine that the insurers will always be at least one step ahead.

    Here’s more from Just Care:

  • Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers

    Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers

    Since 2018, the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) has warned that Medicare Advantage (MA) plans sometimes deny enrollees’ requests for essential services they need.1 2

    In response to these findings, the Centers for Medicare and Medicaid Services (CMS) finalized a 2024 rule to clarify “clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in traditional Medicare.”3 Unfortunately, providers report little improvement since the rule became effective in January. Inappropriate denials continue to cause poor outcomes for patients, hospital readmissions and increased waste of taxpayer dollars.

    Inpatient Rehab Denials

    The 2024 MA rule did not help U.S. Air Force veteran and Pearl River, LA resident George Carrigan. After complications from diabetes required an amputation of his leg, Humana denied his doctors’ recommendation for care at an inpatient rehabilitation facility (IRF), despite Medicare rules listing amputation as a condition requiring such services.4

    Humana’s two denial letters said he did not need supervision from a rehab physician or interdisciplinary care team, even though these clinicians would have helped control his diabetes, monitored the healing of his wound, managed his medications, and prepared him to return home independently. “The services you need can be provided safely in other settings,” wrote Humana, before sending him to a less expensive setting where his condition deteriorated.

    Carrigan’s daughter and family caregiver, Colleen Fickle, said her dad slipped in the nursing home’s shower and now needs wound care on the amputated limb. Poor catheter maintenance also caused him to be readmitted to the hospital with sepsis. Fickle, who works full time while also caring for her child with a brain injury, said her father is now bedbound at home and dependent on family. She believes none of these complications would have happened and that her father would be walking today if Humana had permitted him to receive close medical supervision at an IRF.5

    Mandeville resident William Sercovich, also a U.S. Air Force veteran, suffered two strokes and faced multiple denials before Humana approved his request for IRF services. Both Humana denial letters repeated Medicare’s rehab criteria without explaining why Sercovich did not need a rehab doctor, intensive team or three hours of therapy per day.

    “We were in the hospital for two weeks longer than we should have been because of denials from the insurance company,” said his daughter, Sondra Sercovich. “I hope people take action, so it doesn’t take so many denials to get the proper medical care.”

    The OIG estimated a difference of more than $8,500 in average payments per stay between IRFs and nursing homes for 2018.6 OIG has also warned that MA plans may deny needed care “in an attempt to increase their profits,” misusing funds that CMS paid for people’s healthcare.7 In 2022, OIG physicians audited MA care denials for IRF services and found that in some cases patients met admission criteria, needed higher-level care and alternatives were insufficient to meet their needs.8 Studies have found that MA enrollees “are more likely to enter lower-quality nursing homes compared to fee-for-service enrollees.”9

    When used appropriately, prior authorization can limit low-value services, but healthcare providers also caution that “cost containment provisions that do not have proper medical justification can put patient outcomes in jeopardy.”10

    A recent Kaiser Family Foundation (KFF) study comparing MA plans found that “prior authorization requests were most common for Humana plans.”11 Humana did not respond to requests for comments on its prior authorization practices under new federal rules.

    This year, CMS warned MA plans they may not deny a hospital patient’s request for discharge to an IRF or redirect care to a different setting if a physician orders these services and the patient qualifies under Medicare coverage rules.12 Yet, plans have significant leeway in how they interpret this directive, and families often lack the time to appeal when the patient is ready to leave the hospital.

    Fickle said her father needed intensive therapy at Northshore Rehabilitation Hospital in Lacombe, LA. Speaking of the value of IRF care, the hospital’s CEO Laurel Dupont said “one single hospital readmission would cost [MA plans] as much if not more than the entire rehab stay. Northshore Rehab had zero readmissions of an amputee patient during all of 2023.” A study by Dobson DaVanzo & Associates comparing IRF and skilled nursing facility patients found that IRF patients returned home earlier and remained there longer, with lower mortality rates, emergency room visits and hospital readmissions.13

    Several providers report concerning automatic denials for IRF services. In recent months, TIRR Memorial Hermann Health System in Houston reported receiving automatic MA denials for 90% of prior authorization requests. “If they give us a denial, they’ll say you can go to [a peer-to-peer call with our physician] or you can go ahead and discharge to a nursing home, and I’ll give you that approval now,” said financial clearance manager Courtney Roberson, adding that these automatic denials often keep a patient in the hospital for four to five days longer, taking weekends into account.

    Patients also stay in the hospital longer because MA plans are not required to include IRFs in their provider networks, even though IRF services are a Medicare covered benefit. “It’s not right for Medicare beneficiaries to not have access to this level of care,” said TIRR Memorial Hermann CEO Rhonda M. Abbott. “It doesn’t make sense to eliminate a whole level of care.”

    Last year during a congressional hearing, the American Hospital Association (AHA) described how MA plans financially benefit from these post-acute care delays, explaining that “the plan has already paid the hospital a flat rate for care and is either delaying or attempting to avoid discharging the patient to the next site of care, which would require a separate, additional reimbursement. AHA claims data analysis reflects that length of stay in the referring hospital is typically longer for MA beneficiaries than traditional Medicare beneficiaries being discharged to a post-acute setting.”14

    These transfer delays also contribute to the overcrowding of emergency departments. “An example is a patient who is on a regular floor bed who needs to go to post-acute care,” said Baton Rouge emergency physician Dr. John Jones. “I need that bed for my next congestive heart failure patient who’s in the emergency department, and I can’t put them in there because it’s being occupied by somebody who’s waiting three days over the weekend to get placed.”

    Cardiology and Cancer Care

    MA plans also deny care for patients who need high-quality, Medicare-covered cardiology and cancer care services.

    Cardiologist Dr. Joe Deumite, in Baton Rouge, offered two examples. In one case, Humana twice denied care to a man who needed a pacemaker. “He had 73 episodes where his heart paused for more than three seconds and several episodes where his heart paused for up to 5.2 seconds,” he said, adding that the care was finally approved by an independent review entity.

    In another instance, Dr. Deumite said a woman who suffers from irregular heart rhythms has had to go to the emergency room and take medications because Humana denied her appeals to receive a cardiac ablation. “There are several heart rhythms that respond to ablation, where you just slide up a catheter and cauterize a circuit, and its curative.”

    In April, Baton Rouge medical oncologist Dr. Gerald Miletello recorded a social media video testimonial where he described a dangerous care delay for one of his lung cancer patients.15 “A six-week delay is not following the guidelines because you can easily die with stage four cancer in six weeks,” he said.

    Radiation oncologist Dr. William Russell, in Baton Rouge, said his patients have faced delays when they need to start concurrent chemotherapy with radiation. He also criticized MA plans’ requirement that he conduct a CT scan before they will approve a PET scan. “You have to do diagnostic tests that are not going to be as relevant as the one that you wanted,” he said. “It costs the payers more money to go through that process.” The 2024 MA rule prohibits this practice of step therapy for non-drug services.

    Medical oncologist Dr. Michael Castine, in Baton Rouge, said MA plan documentation requests require him to factor in 10 days between planning and implementation of a patient’s cancer treatment. He mentioned risks for patients with small cell lung cancer, aggressive lymphomas or risks of brain metastasis, warning that “a delay of treatment by a week or two might actually change the whole plan.”

    Peer to Peer Frustrations

    Physicians also criticized the quality of communication they received from MA plan physicians when they call to appeal a patient-care denial.

    “They’re making it up as they go along,” said physical medicine and rehabilitation physician Dr. Adam Carter, who serves as medical director of ClearSky Health Rehabilitation Hospital in Flower Mound, Texas. “I see them as constrained by their employer.”

    “You can almost tell by the first 10 seconds into your conversation whether it’s going to work or not, because you can tell whether that physician is reasonable,” said Dr. Deumite. “They’re looking at year-and-a-half old guidelines.”

    Policy Solutions for Improving Medicare Advantage

    Federal leaders have designed a broad range of solutions to help hold MA plans more accountable. Some changes will not begin until 2026, and stakeholders want additional timeliness and transparency requirements for meaningful patient-care improvements.

    Timeliness

    Today, MA plans must make a prior authorization decision within 14 business days for standard requests and 72 hours for expedited or emergency requests. In 2026, the deadline for standard requests will become seven business days. Stakeholders have called for a 24-hour deadline for emergency requests; pending federal legislation would suggest, but not require, CMS to institute such an expedited timeline.16 17

    Reporting

    In 2026, MA plans must begin publicly reporting aggregate contract-level prior authorization metrics, including denial rates and timeliness. Much of this information already exists today. According to KFF, MA plans denied 3.4 million prior authorization requests in 2022. Only one in ten denials were appealed, but more than 8 out of 10 appeals resulted in overturning the denial. With limited data, it’s not possible to determine the initial reasons for these improper care delays. A study by Premier found that MA denials are more common for higher cost treatments, and that hospitals’ average administrative cost to fight these denials is nearly $20 billion a year.18

    Federal leaders, including Louisiana’s U.S. Sen. Bill Cassidy, and multiple provider groups have asked CMS to require MA companies to report more specific and meaningful data.19 20 KFF researchers found that “substantial data gaps remain that limit the ability of policymakers and researchers to conduct oversight and assess the program’s performance, and for Medicare beneficiaries to compare Medicare Advantage plans offered in their area.”21 KFF also found that “without plan-level data, by type of service, it will not be possible to determine whether plans are complying” with the 2024 MA rule.

    KFF also reported that MA companies “do not report the reasons for prior authorization denials to CMS. If most denials of prior authorization requests are because the service was not deemed medically necessary, efforts to increase transparency of the coverage criteria, such as those recently included in a final rule, may be more likely to have an impact.” KFF has also pointed to a lack of transparency related to decisions from the independent review entity that considers appeals after an MA physician denies a request.22

    CMS opted against requiring plan-level data in 2026, saying it did not want to overwhelm consumers and that it wanted to “limit plan burden.”23 The agency will consider more detailed reporting requirements during future rulemaking.

    Internal MA Plan Monitoring

    CMS now requires all MA plans to establish a Utilization Management Committee to review prior authorization policies annually and ensure compliance with traditional Medicare’s national and local coverage guidelines.24 The AHA urged the Medicare Payment Advisory Commission to monitor whether these committees will have authority to overturn harmful policies, writing that “many providers fear that these committees will serve as little more than a rubber stamp for plan policies.”25

    During the public comment period on the 2024 MA final rule, health insurance companies argued that forcing them to follow traditional Medicare’s clinical criteria would lead to “fewer affordable, high-quality plan choices for beneficiaries” and “adverse health impacts.”

    “CMS in the rule does give MA plans certain limited sets of circumstances where they can use their own internal coverage criteria when traditional Medicare criteria is not fully established,” said Michelle Millerick, AHA director for health insurance coverage and policy. “Some MA plans are over-extending that limited flexibility, and there’s not necessarily a clear definition of exactly when Medicare criteria is fully established, especially for level of care determinations. Stronger enforcement of these provisions from the 2024 MA final rule is needed to ensure plans do not continue to use more restrictive criteria than Medicare.”

    Denial Letter Language

    Beginning in 2026, CMS said the prior authorization denial letters must be “sufficiently specific to enable a provider to understand why a prior authorization has been denied and what actions must be taken to resubmit or appeal.” The agency said the MA plans’ reason for denial “could include” a variety of explanations, such as “how documentation did not support a plan of care for the therapy or service” or “specifically, why the service is not deemed necessary.” Experts say they are cautiously optimistic, but that it remains to be seen how effectively CMS will enforce this policy for patients like Carrigan and Sercovich.

    Targeted Auditing/Aggressive Enforcement

    This year, CMS said it will conduct routine and focused audits to assess compliance with the 2024 MA rule. In a statement, the agency said that it “may issue compliance and enforcement actions, including civil monetary penalties to MA organizations who fail to comply with our regulations.” Providers may send complaints with specific examples of MA plans’ noncompliance to [email protected].

    The OIG recently announced plans to audit MA IRF denials and will issue a report in 2026.26 “I can tell you with great certainty that you will see us expanding our oversight of Medicare Advantage in the coming months and years,” said HHS Inspector General Christi A. Grimm during a recent speech to MA company leaders. “We want Medicare Advantage to be successful. OIG’s work helps ensure that the program works as intended for Medicare enrollees and for taxpayers.”27

    In a statement for this article, OIG said providers may email specific concerns to the agency at [email protected]. “Input from health care providers about managed care practices are regularly sent to relevant subject matter experts, including in our agency’s leadership, for their awareness and to inform our work,” wrote OIG.

    Last year, the federal government paid MA plans more than $454 billion to provide high-quality care to more than 30 million people.28 KFF reports that nearly 60 percent of Louisiana’s Medicare beneficiaries are enrolled in an MA plan this year.29 Providers have applauded the OIG for exposing dangerous care denials and for calling on MA corporate leaders to provide better value to patients and taxpayers.30 “The Medicare Advantage plans aren’t going to change until their board of directors at the company understands as a matter of corporate policy that this isn’t the way to go,” said Dr. Carter.

    [1] https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp

    [2] https://oig.hhs.gov/reports-and-publications/all-reports-and-publications/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/

    [3] https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f

    [4] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/downloads/fs1classreq.pdf

    [5] https://www.facebook.com/LAHospitals/videos/252495247935007

    [6] https://oig.hhs.gov/documents/evaluation/3150/OEI-09-18-00260-Complete%20Report.pdf

    [7] https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf

    [8] https://oig.hhs.gov/documents/evaluation/3150/OEI-09-18-00260-Complete%20Report.pdf

    [9] https://pubmed.ncbi.nlm.nih.gov/29309215/

    [10] https://www.ama-assn.org/system/files/principles-with-signatory-page-for-slsc.pdf

    [11] https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022

    [12] https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf

    [13] https://amrpa.org/portals/0/dobson%20davanzo%20final%20report%20-%20patient%20outcomes%20of%20irf%20v_%20snf%20-%207_10_14%20redated.pdf

    [14] https://www.aha.org/testimony/2023-05-17-aha-statement-senate-subcommittee-medicare-advantage-delays-and-denials

    [15] https://www.facebook.com/LAHospitals/videos/1156382158614094

    [16] https://www.congress.gov/bill/118th-congress/senate-bill/4532/text

    [17] https://amrpa.org/Portals/0/AMRPA%20Comments%20on%20MA%20Data%20RFI%20May%202024_Final.pdf

    [18] https://premierinc.com/newsroom/blog/trend-alert-private-payers-retain-profits-by-refusing-or-delaying-legitimate-medical-claims

    [19] https://www.cassidy.senate.gov/newsroom/press-releases/cassidy-warren-blackburn-cortez-masto-call-for-better-medicare-advantage-data-collection-reporting/

    [20] https://www.aha.org/lettercomment/2024-05-29-aha-rfi-response-cms-medicare-advantage-data-and-oversight

    [21] https://www.kff.org/medicare/issue-brief/gaps-in-medicare-advantage-data-remain-despite-cms-actions-to-increase-transparency/

    [22] https://www.kff.org/private-insurance/issue-brief/final-prior-authorization-rules-look-to-streamline-the-process-but-issues-remain/

    [23] https://www.govinfo.gov/content/pkg/FR-2024-02-08/pdf/2024-00895.pdf

    [24] https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C/section-422.137

    [25] https://www.aha.org/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket

    [26] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp

    [27] https://oig.hhs.gov/documents/speeches/1106/IG-Grimm-RISE-transcript.pdf

    [28] https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends

    [29] https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/

    [30] https://youtu.be/fDzAb-6aog8?si=KIuiXj23d2yr8eoP

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