In case you missed it, the U.S. Senate Permanent Subcommittee on Investigations released a report detailing how three of the nation's largest Medicare Advantage insurers are increasingly denying post-acute care coverage to seniors and individuals with disabilities. Advanced technology systems using artificial intelligence (AI) were a primary factor in these denials, as AI was used to either flag costly coverage requests and minimize the approved coverage or deny the claim outright, resulting in limited access to critical care for hundreds of thousands of Medicare Advantage beneficiaries.
From 2019 to 2022, denials for post-acute coverage rose at an alarming and disproportionate rate and occurred more frequently than denials for other types of care. According to the report:
“The data provided by the companies show that, not only did insurers deny prior authorization for post-acute care more often than other services, but that the rate of denial was substantially higher for some companies. For UnitedHealthcare and CVS, 2022 denial rates for prior authorization of post-acute care services were approximately three times higher than the companies' overall denial rates. In the case of Humana, rates for 2022 were over 16 times higher."
The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) President and CEO Clif Porter said in a statement:
“This report should concern all of us because at the heart of it is the outright denial of care to seniors when they needed post-acute care the most. Insurers and artificial intelligence should not determine if or how long a senior needs to recover in a skilled nursing facility—that's a decision that should be made by the patient and their care team. We will continue to advocate that these plans be held accountable for unfair practices."
Additionally, AHCA/NCAL along with American Medical Rehabilitation Providers Association (AMRPA), National Association of Long-Term Hospitals (NALTH), the National Alliance for Care at Home (The Alliance) and LeadingAge released a joint statement raising concerns over insurance companies' use of artificial intelligence, algorithms and other predictive technologies to determine whether a prior authorization should be accepted or denied for patients. This coalition of post-acute care providers has long advocated for transparent processes regarding care denials by MA plans, including the identification of the health professional who reviewed the request for coverage. The joint statement issued last week said in part:
“Our organizations, representing inpatient rehabilitation hospitals and units (IRFs), long-term care hospitals (LTCHs), skilled nursing facilities (SNFs), and home health agencies (HHAs), have long raised concerns that MA plans too often inappropriately delay and deny access to post-acute care, causing real harm for patients seeking to fully recover from serious injuries, illnesses, disabilities, and chronic conditions. Our members consistently report that these MA plan practices have a direct negative impact on beneficiaries' long-term health, function, and ability to maximize their recovery, especially when they limit access to benefits that are fully covered for those enrolled in Traditional Medicare."
This report was covered by Axios, Politico Pro, Fierce Healthcare, MedPage Today, Modern Healthcare, Skilled Nursing News and STAT News, among others.
Read the AHCA/NCAL statement on the issue HERE and the post-acute care coalition joint statement HERE.