The nation’s three largest Medicare Advantage insurers increasingly refused to pay for rehabilitative care for seniors in the years after adopting sophisticated technologies to aid in their coverage decisions, a Senate investigation found.
UnitedHealth Group, Humana, and CVS Health targeted denials among older adults who were requesting care in nursing homes, inpatient rehab hospitals, and long-term hospitals. As of 2022, those three insurers were turning down roughly a quarter of all requests for post-acute care among their Medicare Advantage enrollees, according to the congressional report.
Well sure, once you knock out 25% of claims, the approval process accelerates.
Humana held training sessions for employees guiding them on prior authorization requests for long-term acute care hospitals, the most expensive type of post-acute care, according to the report The denial rate grew by 54% from 2020 to 2022. The Senate report does not signal whether Humana uses AI to deny prior authorization requests but notes the company has contracted with naviHealth since 2017.
CVS predicted in 2018 the company saved more than $660 million from denying prior authorization requests for inpatient facilities. The company said an internal predictive model designed to “Maximize Approvals” was deemed too catastrophic for the bottom line.
By December 2022, UnitedHealthcare had a working group to determine how machine learning could predict which post-acute care cases were most likely to be appealed and overturned. The company’s post-acute care denial rate had already increased from 10.9% in 2020 to 22.7% in 2022.
I expect this to be resolved in court.
“The report significantly misrepresents CVS Health’s use of prior authorization,” said a company spokesperson. “Many of the documents cited are outdated, while others are drafts or were used for internal Company deliberations and therefore are not reflective of final decisions.
“This is a partisan report laden with errors and misleading claims,” said a Humana spokesperson. “In fact, Sen. Blumenthal’s team declined to correct those errors and mischaracterizations that Humana identified after reviewing certain heavily redacted excerpts prior to the report’s release.”