JustCare

Tag: UnitedHealth

  • New OIG report finds taxpayers pay billions extra for Medicare Advantage insurers’ in-home visits

    New OIG report finds taxpayers pay billions extra for Medicare Advantage insurers’ in-home visits

    For years, government agencies and independent experts have reported that Medicare Advantage insurers game the Medicare payment system to generate billions of dollars in extra revenue from the government. A new report from the Office of the Inspector General focuses on how insurers use home visits as a way to add diagnoses to enrollee medical records and increase their Medicare reimbursements.

    The government pays Medicare Advantage insurers a flat upfront amount for each enrollee. The amount is based on what the government spends in traditional Medicare. But, the government increases that amount for “sicker” patients–patients with more diagnosis codes.

    So, insurers do what they can to increase the amount they get from the government; they “upcode” or add diagnosis codes to enrollee records. They engage nurses to visit enrollees at home and identify more diagnoses for these enrollees. The home visits could be value-added if the insurers provided care tailored to these diagnoses. But, the OIG reports that Medicare Advantage insurers generally simply bill the government more for these enrollees. They do not conduct follow-up visits or deliver other services related to the added diagnoses.

    On average, the insurers generate an extra $1,869 from each home visit. In fiscal year 2023, these visits translated into $3.73 billion for UnitedHealth alone. Not surprisingly, UnitedHealth contends that the home visits add value to the care they provide.

    What additional diagnoses did the nurses who conducted home visits tend to find? They found vascular disease, depression, morbid obesity, chronic obstructive pulmonary disease and rheumatoid arthritis most frequently. They also found enrollees with complications resulting from their diabetes.

    Now what? The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, has never been successful at recouping the overpayments. But, it has ended payment to insurers for certain diagnosis codes that are commonly added during in-home visits and do not result in further treatment. It’s a start, but CMS clearly needs to do a lot more.

    Here’s more from Just Care:

  • Home visits: Another way Medicare Advantage plans gouge taxpayers

    Home visits: Another way Medicare Advantage plans gouge taxpayers

    Policymakers who claim to be tough on crime continue to turn a blind eye to what appears to be multi-billion dollar corporate health insurer crimes in Medicare Advantage. Anna Wilde Mathews and colleagues report for The Wall Street Journal on millions of home visits to Medicare Advantage enrollees that increased insurer revenues by $15 billion in three years.

    The government’s defective payment system to insurers rewards them for adding diagnoses codes to their enrollees’ medical records. When nurses conduct homes visits, they identify new diagnoses that increase insurer revenues from the government. Insurers can add diagnosis codes to enrollee records even if a doctor doesn’t perform a procedure to treat the diagnosis.

    By the WSJ’s account, the nurses conduct screenings during their home visits that permit the insurers to collect $1,818 more on average per visit. In total, between 2019 and 2021, those visits lined the insurers’ pockets by an additional $15 billion.

    UnitedHealth was best equipped to squeeze money out of those nurse home visits, collecting $2,735 per visit on average. It conducted 2.7 million nurse visits last year alone. Humana did a relatively good job of maximizing revenues from those home visits, collecting $1,525 per visit on average. CVS/Aetna received an additional $232 per nurse home visit.

    One former UnitedHealth nurse explained that she did an average of six home visits each day. As part of the visit, she would warm up people’s toes to see how well blood flowed to them. The goal was to diagnose them with peripheral artery disease, which would mean an average of $2,500 a year more for UnitedHealth.

    The nurse said she did not believe that the device she used for the test worked properly to diagnose peripheral artery disease. But, no one seemed to care, and she was told to keep using it. UnitedHealth added the diagnosis to 568,000 medical records over the three years, as a result of using this device.

    “Other nurses interviewed by the Journal said many of the diagnoses that home-visit companies encouraged them to make wouldn’t otherwise have occurred to them, and in many cases were unwarranted.”

    UnitedHealth received $1.4 billion from the peripheral artery disease diagnosis. Medicare says it is no longer making additional payments to insurers for peripheral artery disease diagnoses.

    UnitedHealth appears to take the cake when it comes to additional patient diagnoses from the nurse home visits. Its nurses detected hyperaldosteronism 246,000 times over the three-year period the WSJ investigated, which was worth $450,000 to the company. All other insurers combined diagnosed the condition less than 24,000 times and collected $42 million as a result.

    The WSJ had previously reported that insurers billed Medicare $50 billion for enrollee health conditions that physicians never treated. Of that, thirty percent stemmed from nurse home visits. The WSJ found that many diagnoses were wrong or questionable.

    To be sure, a nurse’s home visit could be helpful to a patient. The nurse could help with medication management, for example. But, considering that the WSJ found little if any follow-up after these nurse visits, the real benefits is to the bottom lines of the health insurance companies offering Medicare Advantage.

    Here’s more from Just Care:

     

  • What’s more dangerous than dozens of insurers offering Medicare Advantage? UnitedHealth for All

    What’s more dangerous than dozens of insurers offering Medicare Advantage? UnitedHealth for All

    Hayden Rooke-Ley et al. write in the The New England Journal of Medicine about the dangers of a corporate health insurer takeover of Medicare. Medicare Advantage, which is administered by corporate health insurers, is growing like wildflowers. Unless the government ends overpayments to Medicare Advantage plans, a future of UnitedHealth for everyone with Medicare is not unlikely–undermining competition, driving up costs, and putting patient health at risk.

    UnitedHealth is the largest health insurer in the US. In part thanks to the billions of dollars of fixed upfront (capitated) payments it receives from the government to offer Medicare Advantage plans, UnitedHealth is acquiring physician practices and clinics. Indeed, UnitedHealth is the largest employer of physicians in the nation. It also owns the third largest Pharmacy Benefit Manager, OptumRx. And it even owns an enormous provider payment system.

    The government’s payment system for Medicare Advantage, through upfront capitated payments to insurers who bear the full risk of providing Medicare benefits, creates powerful financial disincentives for corporate insurers to withhold patient care and reimbursements to providers every way they can. In sharp contrast, Traditional Medicare, which is administered directly by the government, has a fee-for-service payment system that incentivizes providers to deliver health care.

    Recently, UnitedHealth’s payment system, Change Healthcare, was hacked. As a result, UnitedHealth held up reimbursements to hospitals, physicians and pharmacies. In turn, many of these providers were unable to meet payroll and to deliver care as needed.

    Corporate control of health care is a threat to our health care system. Change Healthcare processes payments in Traditional Medicare as well as in Medicare Advantage. After the Change hack, while UnitedHealth left providers in Medicare Advantage with long waits for reimbursements, the Centers for Medicare and Medicaid Services stepped in on behalf of providers in Traditional Medicare to ensure they were paid. Unlike UnitedHealth, the federal government was most concerned about ensuring providers were paid.

    Humana and CVS are not as large as UnitedHealth, but they too are building enormous positions in senior care, post-acute care, and in-home services. Cigna, Centene and Elevance are also buying up health care businesses.

    This vertical integration in the corporate health insurance sector comes with serious risks. It undermines competition and drives up costs. It can also bankrupt physicians and hospitals and endanger patient care.

    Some argue that corporate control and consolidation in the health care sector delivers efficiencies that can save money and improve care. For example, insurers have an incentive to keep people from going to the ER because they are paid a fixed amount and can pocket what they don’t spend on care. They also have an incentive to keep members healthy so they spend less on their care.

    But, insurers have a financial incentive to keep people from going to the ER and getting other costly care when they need it. The Office of the Inspector General has found that they engage in widespread inappropriate delays and denials of care. So, whatever the benefits of consolidation, the risks are costly and dangerous.

    Insurers also game the Medicare payment system to reap billions of dollars in additional revenue. Last year, they received $83 billion in overpayments, according to the Medicare Payment Advisory Commission.

    The notion that insurers’ employment of physicians eases physicians’ administrative burden is misplaced. Insurers control staffing and scheduling, burdening physicians with a large caseload. In fact, insurers can keep physicians from putting the health of their patients first. Insurers can call the shots regarding the number of patients each clinician sees. And, insurers can incentivize providers to withhold care.

    Insurers like UnitedHealth and CVS have so much money and power at this point that the Department of Justice and Federal Trade Commission have not been successful at blocking monopolistic acquisitions such as United’s purchase of Change Healthcare. UnitedHealth prevailed in court.

    Theoretically, Congress could put an end to vertical consolidation by passing legislation that would prevent insurers from employing physicians and controlling our care-delivery system. Those reforms appear to be a pipe dream, given the gridlock in Congress.

    For sure, Congress should eliminate insurer overpayments. That would cripple the insurers quickly. But, that’s equally unlikely, given the politics.

    At the very least, Congress and the Administration should warn people with Medicare of the dangers they face in Medicare Advantage, instead of misleading them to think they will get the same benefits as in Traditional Medicare. While that might be the case in theory, Medicare Advantage enrollees do not get the same benefits as people in Traditional Medicare in practice. Medicare Advantage plans limit enrollees’ access to doctors and hospitals, impose administrative obstacles to care, and second-guess treating physicians, often inappropriately denying critical care.

    Here’s more from Just Care:

  • Humana and CVS will raise costs for Medicare Advantage enrollees in 2025

    Humana and CVS will raise costs for Medicare Advantage enrollees in 2025

    Humana and CVS intend to raise premiums and reduce benefits on their MA plans in 2025, reports Rebecca Pifer for Health Care Dive. They want to increase their profits further, even though the government already overpays them billions of dollars a year.

    As many as 700,000 CVS and Humana MA enrollees could switch to other plans, and CVS and Humana don’t seem to care. UnitedHealth is likely to grow its business in the process, depending upon whether it decides to cut benefits and/or raise premiums. The insurers offering Medicare Advantage are unlikely to increase their out-of-pocket caps and their deductibles, which people with Medicare apparently care most about.

    We won’t know what these insurers will decide to do until October. To be clear, CVS and Humana, like all of the big insurers, are first and foremost in the Medicare Advantage business to generate profits for their shareholders. Enrollee needs are secondary. They will exit markets where they don’t see good profits.

    CVS, Humana and UnitedHealth all own medical provider groups. So, they are likely to continue their MA businesses in counties in which those groups have clinics and they can generate better profits. 

    Insurers are most likely to raise copays for specialty care, which people can’t really wrap their heads around before enrolling and needing specialty care. Insurers also could cut supplemental benefits, such as money for home improvements and pet care.

    The insurers have a lot of discretion, but they can’t change anything they want. The government limits their ability to change “total beneficiary cost,” which is limited to $40 per enrollee each month. 

    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:

  • UnitedHealth care delays, denies and grows ever bigger

    UnitedHealth care delays, denies and grows ever bigger

    At the same time that UnitedHealth is growing its Medicare Advantage business, it is growing many of its other businesses and controlling a sizeable portion of the health care sector, often to the detriment of patients and providers. Dan Diamond, Christopher Rowland and Daniel Gilbert report for the Washington Post on the attention Congress is now giving to UnitedHealth. Will Congress rein in UnitedHealth and hold it accountable for its bad acts. Can the federal government break up UnitedHealth at this point, or is it too big to fail?

    Chairman Ron Wyden, who heads the Senate Finance Committee, is holding a hearing with Sir Andrew Witty, UnitedHealth’s CEO. United is now a $400 billion company, with $22 billion in profits in 2023, and the biggest health insurer, as well as the biggest employer of physicians in the US; it employs about 10 percent of providers. It also processes about a third of provider claims for reimbursement through its Change Healthcare subsidiary. Recently, its cybersecurity system was hacked, and UnitedHealth forced tens of thousands of physicians and hospitals to go without pay; some providers were forced to take out loans and some patients had to pay out of pocket for care.

    It is not at all clear why UnitedHealth did not address grave gaps in Change Healthcare’s security when it acquired the company a few years ago. Nor is it clear that UnitedHealth is holding anyone at the corporation accountable for this failure.

    How can Congress help ensure UnitedHealth appropriately covers care and coverage and hold the corporation account when it fails to do so? In the words of Don Berwick, former head of the Centers for Medicare and Medicaid Services, “They’ve grown too big for this country’s good, and for their own good.” “They became the best at playing the game of charging the federal government more and using that wealth to gain political power, advertising power, some changes in benefits.” Some say UnitedHealth presents an economic and national security risk.

    Republicans and Democrats agree that the size and power of UnitedHealth raises serious concerns. Senator Wyden, a Democrat, wants Witty to explain his company’s use of prior authorization, which too often keeps people from getting needed care. He is concerned with the ways UnitedHealth increases health care costs. Congressman Buddy Carter, a Republican, says “It needs to be busted up.” Here, here!

    The Justice Department has tried to prevent some of UnitedHealth’s mergers and acquisitions, but UnitedHealth has put up legal challenges and tends to prevail. Hayden Rooke-Ley, a senior fellow at the American Economic Liberties Project, an antitrust-focused nonprofit, explains the consequences: “What we are seeing now is there are really significant risks of letting a company like United own a physician group, ambulatory surgical centers, a mail order pharmacy, home health providers … and claims processing and revenue cycle management.”

    The fact remains that a number of Democrats and Republicans receive significant campaign contributions from UnitedHealth, which they depend upon. Moreover, many policymakers receive veiled threats from UnitedHealth if they don’t support the corporation. For now, you can expect UnitedHealth to grow and our healthcare system to remain at serious risk of higher costs and inappropriate denials of care as a result.

    Here’s more from Just Care:

  • Out-of-network care: Don’t trust your insurer to pay the bills

    Out-of-network care: Don’t trust your insurer to pay the bills

    MultiPlan, a data analytics firm, works with UnitedHealthcare and many big insurers to calculate the amount insurers should pay for out-of-network care. As Chris Hamby reports for the New York Times, MultiPlan and the insurers make more money for themselves, the less they pay for employees’ care. So, many working people can’t trust their insurer to pay for their out-of-network care.

    Are MultiPlan and the insurers simply “containing” costs for employers or profiting wildly at the expense of working people? Profiting wildly. The less they pay for workers’ out-of-network care, the more revenue they generate for themselves. In 2023, MultiPlan advised insurers not to pay $23 billion in health care bills they claim were provider overcharges.

    How insurers benefit from out-of-network coverage, an example: The oncologist charges $100,000 for out-of-network care. MultiPlan says the appropriate charge is $5,000. The insurer pays $5,000. The employer saves. And, MultiPlan and the insurer receive a fee from the employer that is a high percentage of the “savings.”

    What’s most insane about this whole scheme is that in many cases the fees that MultiPlan and the insurer collect are way more than the physician or hospital receives as payment for services from the insurer! UnitedHealthcare charges employers around 30 to 35 percent of the difference between what the provider bills and what the insurer pays. MultiPlan receives an additional fee. The cancer patient could be stuck with a $95,000 bill. The less the employer pays, the more MultiPlan and the insurer earn in fees.

    How does MultiPlan calculate the insurers’ payment? Somehow, MultiPlan claims that the amount it determines to be the fair out-of-network rate is  “defensible, repeatable and completely transparent” and independent of insurance company influence.” Orwellian, to say the least.

    Don’t assume that your employer’s insurer doesn’t rely on MultiPlan. MultiPlan calculates out-of-network payments for more than 60 million people enrolled in 100,000 different health plans.

    What must workers pay for their out-of-network care? They could be stuck paying whatever the difference is between what the insurer pays and the physician bills. They are also likely to forgo needed care down the road for fear of incurring more bills.

    Who’s watching the store for workers? Honestly, no one. Regulators do not get involved with employer health plans, for the most part.

    Fool me twice? 15 years ago, the New York Attorney General intervened to stop a similar UnitedHealthcare scheme: “A payment system riddled with conflicts of interest had been shortchanging patients, and at its core was a data company called Ingenix, a subsidiary of UnitedHealth.” They lower their payments to providers inappropriately. requiring patients to pay more. UnitedHealth paid $350 million and new regulations were put in place to prevent this from happening again.

    Here’s more from Just Care:

  • Hospitals, physicians and pharmacies left unpaid after a UnitedHealth cyberattack

    Hospitals, physicians and pharmacies left unpaid after a UnitedHealth cyberattack

    What happens when a corporate health insurance company, Change Healthcare, a division of UnitedHealth Group, has its computer system hacked and can’t pay claims electronically? Even when Medicare claims are at issue, the Centers for Medicare and Medicaid Services (CMS) can only urge UnitedHealth to behave ethically. Darius Tahir et al. report for Kaiser Health News that physicians, hospitals and pharmacies are left in the lurch.

    Our health care system is so poorly designed that even when a government program is involved, the government can do little more than ask the insurer to mitigate a problem–even serious problems such as inability to pay electronically about 50 percent of all physician claims–voluntarily. The insurer wants to spend as little money as possible to resolve the problem and feels no ethical, let alone legal obligation, to find a workaround. One advocate nails the problem: “the purely optional, do-this-out-of-the-goodness-of-your-heart model clearly is not working.”

    UnitedHealth appears in no rush to help providers, saying its systems for paying claims will get fixed later this month. In the meantime, it has created inadequate workarounds. It is offering practices with hundreds of thousands of dollars in weekly revenue as little as $540 a week.

    CMS is asking UnitedHealth to do better. Providers need more money. Alternatively, CMS is suggesting that providers file paper claims or switch away from Change Healthcare to a different company to pay their bills, which for many providers is easier said than done.

    The White House is also asking UnitedHealth to do more to help ensure providers are reimbursed appropriately and without delay.

    Meanwhile, some pharmacies are asking patients to pay the full cost of medications. Some physician practices are struggling to pay their bills. They are out millions of dollars.

    Policymakers and experts would like the Biden administration to do more. But, except with regard to claims it pays directly in Traditional Medicare, it has limited authority since it turned over Medicare Advantage claims payment to corporate insurers. Congress should reconsider the consequences of the government not fully controlling claims payment in our healthcare system.

    Saad Chaudhry, an executive at Maryland hospital system raises a darker issue. What is UnitedHealth really up to? He asks, “Do you believe these thieves? Do you believe the organization itself, that has everything riding on their public image, who have incentives to minimize this kind of thing?” Whether you believe UnitedHealth or not, health care providers and their patients should never be in this situation.

    How does the government protect against cyberattacks down the road, when our health care system is so fragmented? There are scores of cyberattacks each year against health care entities. For sure, the government should require system redundancies so that if one insurer is hacked providers have other options for getting paid. But, if the government were in control of claims payments, it would have the power to do whatever workarounds were necessary to ensure payment to providers if its systems were hacked.

    Congress should be on top of this now. One thing’s for sure. Cyberattacks will continue.

    Here’s more from Just Care:

  • Medicare Advantage and other HMOs compromise continuity of care

    Medicare Advantage and other HMOs compromise continuity of care

    If you’re in a Medicare Advantage plan or any health insurance plan that requires you to use in-network health care providers and you have not thought about the fact that you can’t count on your health plan covering those physicians and hospitals over time, you should. In fact, right now, hospitals and physicians are dropping like flies from a large number of health plans. Melanie Evans reports for the Wall Street Journal about the ugly situations patients in these health plans are facing.

    One reason to stay away from Medicare Advantage plans–which cover your care from in-network providers only or which cover only some of the cost of your care from out-of-network providers–is that you might end up having to switch physicians mid-course of treatment. That seems to be happening to tens of thousands of people in Medicare Advantage plans and other health plans in the last couple of years. The corporate health insurers offering Medicare Advantage plans too often are denying payments to hospital systems and forcing physicians to go through multiple hoops to get care approved, at enormous cost to them. So, the hospitals and physicians are fighting back, refusing to contract with the insurers.

    Lots of patients are hearing from their local hospitals and physicians that their insurance will no longer cover their care from these providers. Hospitals want more money and less headache. They say that insurer prior authorization rules are endangering the health and well-being of their patients.

    Patients, in turn, are left in a serious quandary. Stay with their longtime physicians and hospitals and be liable for the full cost of their care, often thousands or tens of thousands of dollars. Or, switch to new hospitals and physicians, which can compromise their health. Moreover, switching care providers is almost always a total headache and challenging in and of itself.

    A lot of the problem stems from the fact that unlike other wealthy nations, the US does not set provider rates, we leave it to the health insurers to negotiate them. It’s a recipe for insanity. If providers have a lot of power, the rates can be excessive. If the insurers have all the power, the rates can be so low as to threaten the quality of care.

    For example, in Medicare Advantage, insurers can spend less if they don’t contract with cancer centers of excellence. But, the latest research suggests that means patients are likely to get poor quality cancer care and face higher mortality rates.

    What’s worse is that our health care system allows insurers offering Medicare Advantage plans and all other health plans the discretion to decide when care is covered. If they’re facing pressure from Wall Street to return greater profits, the insurers can stint on care. The less care they cover, the more money they get to keep and the more they profit.

    In January, UnitedHealth ended some in-network coverage from Mount Sinai in New York City. On March 1, UnitedHealth terminated contracts with other Mount Sinai hospitals. As of March 22, it will end coverage for physicians in the Mount Sinai system. UnitedHealth hasn’t been paying Mount Sinai providers as much as providers at other hospital systems.

    What can you do if your health care providers leave your insurers’ networks? You have some protection against surprise medical bills. And, your insurer is obligated to have adequate networks, so your insurer might continue to cover your care in order to meet network adequacy requirements. But, this is no way to run a healthcare system if you care at all about patients’ health and well-being.

    Here’s more from Just Care:

  • 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: