JustCare

Tag: NaviHealth

  • UnitedHealth’s denials of critical rehab services is under investigation

    UnitedHealth’s denials of critical rehab services is under investigation

    Stat News reports on United HealthCare’s secret rules that deny Medicare Advantage enrollees critical and costly rehab care when they most need it. UnitedHealth literally singled out people with cognitive impairments and nursing home residents for exclusion from coverage of rehab services, even though they needed these services. But, Congressional and administrative scrutiny on UnitedHealth’s practices appear to be affecting the insurer’s behavior for the better, at least for now.

    Stat News obtained internal UnitedHealth documents that advised clinicians who worked for the insurer to deny people care that their treating physicians said was medically necessary. But, in November 2023, the clinicians’ managers told the clinicians that they could consider the individual needs of each patient to determine whether rehab services were medically necessary. Not surprisingly, that directive came on the heels of a Congressional investigation into UnitedHealth’s practices and the Centers for Medicare and Medicaid Services (CMS) saying that it was about to look more closely at UnitedHealth’s denials of services to its Medicare Advantage enrollees.

    Stat News has been reporting on the use of AI by UnitedHealth and other insurers offering Medicare Advantage plans to deny care without regard to patient needs. According to some experts, UnitedHealth has been denying care based on rules that have no evidence base. For example, UnitedHealth’s AI algorithms for determining whether care is medically necessary apparently denied rehab care across the board to most nursing home residents rather than looking at people’s individual care needs as required under Medicare law.

    Some of these nursing home residents were recovering from strokes, big falls and cancer and desperately required rehab services to regain function. Yet, while Medicare Advantage enrollees are supposed to have coverage for the same benefits as people in traditional Medicare, they too often do not.

    Even if you are not enrolled in a UnitedHealth Medicare Advantage plan, you may still have cause for concern. Many Medicare Advantage insurers use NaviHealth’s AI algorithms to deny rehab care. In total, around 15 million Medicare enrollees are at risk.

    NaviHealth has denied the charges against it, claiming that it does review “complex” cases to determine medical necessity. It also claims that the change in protocols to give clinicians more discretion in approving care was unrelated to Congressional and CMS investigations into its practices. “Following a standard review of protocols, we identified an opportunity to simplify care approvals in certain clinically complex conditions that do not require escalated review by a physician medical director for approval. Any adverse coverage decision is made by physician medical directors based on Medicare coverage criteria and supporting clinical records.”

    Unfortunately, CMS does not begin to have the resources or the power to hold UnitedHealth and other Medicare Advantage insurers accountable for their bad acts in meaningful ways. Consequently, people enrolled in these Medicare Advantage plans who end up needing costly and complex care could be at serious risk. Moreover, UnitedHealth and other Medicare Advantage insurers can change their practices at any time to restrict care access, with near impunity, as CMS is not likely to know and penalties are at most mild.

    Here’s more from Just Care:

  • CMS can’t oversee AI denials in Medicare Advantage

    CMS can’t oversee AI denials in Medicare Advantage

    Congressman Jerry Nadler, Congresswoman Judy Chu and 28 other House members recently sent a letter to the Centers for Medicare and Medicaid Services (CMS) urging CMS to assess AI denials in Medicare Advantage. If only CMS could do so effectively and in a timely manner. Not only does CMS lack the resources to do the requisite oversight at the moment, but when it finds Medicare Advantage plans are inappropriately denying care through AI, CMS appears to lack the power to punish the insurers in a meaningful way.

    Bottom line: It seems unlikely that CMS can rein in the Medicare Advantage plans’ use of AI to deny claims at eye-popping rates, even if the insurers offering Medicare Advantage plans deny care without regard to enrollees’ particular conditions, as required.

    In their letter to CMS, the members of Congress express concern about CMS’ Medicare Advantage and Part D prescription drug prior authorization requirements in its 2024 final rule.

    What’s happening exactly? NaviHealth, myNexus and CareCentrix provide Medicare Advantage plans with AI software to restrict coverage based on artificial intelligence. The insurers who rely on AI claim that they also review claims based on patient needs. But, former NaviHealth staff argue to the contrary. Mounting evidence suggests that the lives and health of some Medicare Advantage enrollees are endangered.

    Because CMS does not prevent insurers from using AI to deny Medicare Advantage coverage, members of Congress recognize the challenge for CMS to monitor the use of AI and ensure that claims are properly processed. “Absent prohibiting the use of AI/algorithmic tools outright, it is unclear how CMS is monitoring and evaluating MA plans’ use of such tools in order to ensure that plans comply with Medicare’s rules and do not inappropriately create barriers to care,” the members wrote.

    The insurers will always claim that AI is not making the denial decision, which is true. The insurers are. But, they appear to be exercising little if any independent judgment in many instances. So, the question remains whether the insurers are determining medical necessity based on the medical needs of their enrollees, as they should be. What’s clear is that though Medicare Advantage plans are legally required to provide the same coverage as traditional Medicare, they do not. 

    To help ensurer appropriate oversight of the insurers’ use of AI, among other things, the members of Congress propose that CMS:

    • Require MA plans to report prior authorization data including reason for denial, by type of service, beneficiary characteristics (such as health conditions) and timeliness of prior authorization decisions;
    • Compare the AI determinations against the actual MA plans’ determination;
    • Assess whether the AI/algorithms are “self-correcting,” by determining whether, when a plan denial or premature termination of services is reversed on appeal, that reversal is then factored into the software so that it appropriately learns when care should be covered.

    Here’s more from Just Care:

  • UnitedHealth deprives members of critical rehabilitation care

    UnitedHealth deprives members of critical rehabilitation care

    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:

  • UnitedHealth renames company responsible for massive inappropriate denials

    UnitedHealth renames company responsible for massive inappropriate denials

    A while back, I reported on a story in Stat News that exposed a division of UnitedHealth, NaviHealth that uses artificial intelligence, AI, to deny thousands of Medicare Advantage claims, in seconds. Now, Stat News reports that UnitedHealth is renaming NaviHealth, with all the evidence pointing towards UnitedHealth continuing to deny claims en masse with the help of the renamed company. If you need a reason not to enroll in a Medicare Advantage plan or to disenroll from one, NaviHealth or whatever it’s new name, is as good as any.

    The original Stat News story explained that UnitedHealth, as well as many other health insurance companies, rely on NaviHealth, an AI system, in its medical decisionmaking to inappropriately deny care to people in Medicare Advantage plans. Former employees at NaviHealth report that its AI algorithms wrongly deny care to Medicare Advantage enrollees in serious health.

    Employees at NaviHealth complained in internal communications that insurers were denying care to people who are on IVs in rehab facilities. Medicare should cover up to 100 days in a rehab facility or nursing home for eligible individuals. But, NaviHealth sometimes determines that people need to leave rehab before their treating physicians believe that it is appropriate for them to do so. In 2022, the Office of the Inspector General of the Department of Health and Human Services reported widespread and persistent delays and denials of care in some Medicare Advantage plans, including denials of rehab and skilled nursing services.

    As Stat previously reported, insurance corporations use AI–computer programs–to deny care to Medicare Advantage enrollees with serious diseases and injuries, when traditional Medicare would have covered the care. The NaviHealth system wrongly does not consider individual patient’s needs in its determinations about when to stop covering care. Patients, physicians and NaviHealth workers are “increasingly distressed” that patients are not able to get the care they need as a result of these computer algorithms.

    Here’s more from Just Care:

  • How former CMS head, Tom Scully, privatized and destroyed Medicare

    How former CMS head, Tom Scully, privatized and destroyed Medicare

    David Dayen reports on former Center for Medicare and Medicaid Services (CMS) head, Tom Scully, privatized and destroyed Medicare for The American Prospect.

    Back in 2002, Scully, the administrator at CMS under President George W. Bush, attacked the incentives in the Medicare program. At the time, he was focused on hospital incentives to inflate patient costs, saying “People follow the money, and they’ll find the little niches in the program and they’ll game it, and that’s what happened here.”

    Scully, himself, has taken advantage of these “niches” since leaving government in 2003 for private equity. Scully’s view about health care is Darwinian. People should pay out of pocket for their health care, as they do for their vegetables–survival of the fittest–with help only for the poor.

    Scully doesn’t recognize the value of Medicare negotiating prices for physicians and hospitals. Of course, that’s what has kept Medicare spending down for older Americans and people with disabilities. It’s also one key way other countries get value from their health care systems. In Scully’s view, if you get sick, you should pay for it.

    It’s thinking like Scully’s that has pretty much destroyed our health care system. Physicians and patients have suffered as private equity and big corporations have seen their profits soar. “Scully’s fear of big-government price-fixers has led to the triumph of big private profit-takers, at the cost of doctors, nurses, and patient care.”

    The corporate takeover of health care has also made navigating the system challenging. It’s now so complex. Choice and competition are meaningless. They have not improved quality and they have only increased costs. Unlike with airline travel, restaurants, housing or automobiles, you have virtually no idea if the health plan you choose will deny and delay your care and endanger your health. All you know is that there’s a decent chance that your insurer will not cover your care.

    Health care corporations are in business to help their investors first and foremost. And, in the health care space, they can do so pretty easily, with little accountability, by simply extracting money from the system. Scully knows this full well and helped conceive, design and implement the algorithms that now power NaviHealth–a software AI system that helps insurers to keep more of their government payments by denying or limiting home health, nursing and rehab coverage.

    Scully sold NaviHealth before it was bought by Optum, a division of UnitedHealth. He then went on to push Congress to allow for-profit PACE programs and to invest in InnovAge, which was buying up PACE programs. Soon after, CMS addressed allegations that InnovAge was denying thousands of PACE patients medically necessary services and suspended enrollment in many of InnovAge PACE programs for a time.

    As former head of the Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services, Rick Gilfillan, explains: “When you privatize social goods like health care, you end up getting the worst of both worlds. Because it’s seen as a public good, you can’t let the marketplace operate as it normally would … you get captured regulatory processes that end up facilitating the extraction of wealth by the private sector.”

    Here’s more from Just Care:

  • Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans

    Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans

    Beware of corporate health insurers that use NaviHealth, an AI system tha can inappropriately deny care to people in Medicare Advantage plans. Former employees at NaviHealth report that its AI algorithms wrongly deny care to Medicare Advantage enrollees in serious health, reports Stat News. UnitedHealth, which owns NaviHealth, and other health insurance companies, rely on NaviHealth in their medical decisionmaking,

    Employees at NaviHealth are complaining in internal communications that insurers are denying care to people who are on IVs in rehab facilities. Medicare should cover up to 100 days in a rehab facility for eligible individuals. But, NaviHealth sometimes determines that they need to leave rehab before it is appropriate for them to do so.

    As Stat previously reported, insurance corporations use AI–computer programs–to deny care to Medicare Advantage enrollees with serious diseases and injuries. The NaviHealth system does not consider individual patient’s needs in its determinations about when to stop covering care. Patients, physicians and NaviHealth workers are “increasingly distressed” that patients are not able to get the care they need as a result of these computer algorithms.

    Former medical review employees at NaviHealth say that they were not allowed to use their independent clinical judgment to allow continued stays in rehab facilities when the NaviHealth system said to deny care; they had to follow the algorithms. “That was very different from before we were owned by Optum.”

    As Stat News reports, this is the dark side of AI. Reporters spoke with five former NaviHealth employees, patients, lawyers, experts; they also reviewed internal communications at NaviHealth. For its part, NaviHealth says its algorithms are merely a guide and NaviHealth does not make coverage decisions. But, how often do insurance company medical review staff not follow the NaviHealth “guide” when the medical evidence suggests patients still need care?

    Stat News finds that the NaviHealth algorithms are central to coverage decisions, influencing outcomes. NaviHealth likely is responsible for huge profits for UnitedHealth and other health insurance corporations. But, those profits come at the cost of people’s health and sometimes endanger their lives. Patients’ only resort when NaviHealth denies care is to pay privately for the health care services and appeal the denials. (And, that’s only if they have the means to do so.) Patients have a high likelihood of prevailing, but many of them cannot afford to pay for that care privately.

    Here’s more from Just Care: