Dive Brief:
- Medicare Advantage plans deny post-acute care on a daily or weekly basis for members in a majority of nursing homes — often against the advice of medical professionals, according to a new survey from the American Health Care Association.
- The AHCA, which represents nursing homes, assisted living communities and other providers for elderly and disabled individuals, surveyed more than 360 nursing home providers in May and found that 37% said post-acute care is delayed or denied at least once a week. Another 29% said such decisions come as frequently as every day.
- The findings build on other research suggesting MA plans aggressively restrict care, which critics argue is done to increase their profits. UnitedHealth, the parent company of the largest MA insurer in the U.S., is currently being investigated by lawmakers for potentially impeding care for residents of nursing homes.
Dive Insight:
In MA, the privately run alternative to Medicare, the government pays insurers to manage seniors’ care. The plans can offer a greater range of benefits than in traditional Medicare, such as dental, vision and hearing care along with other add-ons like gym or transportation stipends. However, MA insurers can also put roadblocks to care in place that aren’t allowed in its sister program.
Research has found that MA plans’ utilization management practices, like prior authorizations, harm care access and are frequently overturned upon appeal, exacerbating worries that MA plans might be using the processes to avoid paying for necessary medical care.
Payers’ use of artificial intelligence in coverage determinations is also a cause for concern, given the tools’ propensity to make mistakes that, in this area, can have serious consequences for patients.
The three largest MA payers — UnitedHealthcare, Humana and CVS — intentionally used algorithms to significantly increase claims denials for MA beneficiaries between 2019 and 2022, according to a Senate investigation published last year.
The AHCA’s survey provides new data to one area of that debate: post-acute care, which helps patients recover after an illness or injury. Along with information about the frequency of denials for MA beneficiaries, the survey found more than two-thirds of nursing homes had a situation wherein an MA plan pulled coverage for a resident against medical advice.
More than half of providers said such denials were frequently overturned upon appeal, suggesting the initial denial was should have been approved in the first place.
“Often, we see a resident’s stay cut short prematurely, leaving them with a tough decision to make. Pay out of pocket, or discharge home with the risk of ending up back in the hospital. It makes our job extremely challenging,” one provider wrote in response to the survey.
The AHCA’s findings align with the Senate investigation last year, which found UnitedHealthcare, Humana and CVS denied prior authorization requests for post-acute care at “far higher rates” than other services.
“This constant hoop jumping is resulting in too many skilled nursing patients being discharged too soon against medical advice, threatening their recovery,” Clif Porter, the president and CEO of AHCA, said in a statement. “We want to make sure Medicare Advantage plans are providing the therapy benefits our seniors were promised and are not leaving important — sometimes life-saving — medical decisions to AI or insurers without appropriate guardrails and oversight.”
The issue is increasing importance as more seniors select MA. Currently, more than half of Medicare beneficiaries — some 35 million people — are in the program, according to government data. That share is expected to continue rising.
MA plans generally deny allegations that they stymie necessary medical care, and defend prior authorizations as an important tool to keep a lid on skyrocketing costs. Still, amid growing public attention to care delays and denials, major insurers pledged to reform the processes earlier this summer, including reducing what types of care are subject to prior authorizations.
