<body><div><img src="https://img.particlenews.com/image.php?type=thumbnail_580x000&amp;url=0R5YY3_0wBixUh900" alt="https://img.particlenews.com/image.php?url=0R5YY3_0wBixUh900" width="1920" height="1080" >The country’s three largest Medicare Advantage (MA) insurers obstruct seniors’ ability to receive post-acute care, a scathing report from the U.S. Senate Permanent Subcommittee on Investigations shows.It outlines attempts from UnitedHealthcare, CVS and Humana—which collectively cover nearly 60% of all MA enrollees—to use technology to reject prior authorization claims, all while reaping profit.Between 2019 and 2022, the three insurers denied claims for post-acute care at “far higher” rates than for other types of care, and, in 2022, Humana denials in post-acute care were 16 times higher than the companies’ overall denial rates, the report (PDF) says. UnitedHealthcare and CVS denials were three times higher in the same year.“Insurance companies say that prior authorization is meant to prevent unnecessary medical services,” said Sen. Richard Blumenthal, D-Connecticut, in a statement. “But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions. In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors—simply to make more money. Our subcommittee even found evidence of insurers expanding this practice in recent years.”The committee began the investigation in May 2023 and analyzed more than 280,000 pages of internal documents. The report was produced by Blumenthal’s staff. It reveals the insurers adopted new automated processes to speed up claims decisions, and, simultaneously, denials often increased.The subcommittee is calling on the Centers for Medicare &amp; Medicaid Services (CMS) to collect prior authorization data by service category and conduct audits when denial rates spike in certain areas. They also want more regulation around insurers’ internal prior authorization committees, because even if AI is only used to approve requests, medical professionals may be facing pressure to go along with AI recommendations in the name of efficiency and cost-cutting.Post-acute care data business naviHealth conducts prior authorization for major insurers, including Blue Cross Blue Shield plans, Stat previously reported. In April 2022, naviHealth told customer service representatives to not help providers with prior authorization questions.“IMPORTANT: Do NOT guide providers or give providers answers to the questions,” naviHealth mandated.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.UnitedHealth bought naviHealth in 2020. Since then, naviHealth has rebranded to Optum Home &amp; Community Care, laid off scores of workers and its CEO Harrison Frist resigned, Fierce Healthcare reported. The company is also facing a class-action lawsuit over naviHealth’s denial practices.“This majority staff report mischaracterizes the MA program and our clinical practices, while ignoring the Centers for Medicare &amp; Medicaid Services criteria demanding greater scrutiny around post-acute care,” said a UnitedHealthcare spokesperson.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.So in 2021, hoping to save money in MA, CVS deployed AI to reduce spend in skilled nursing facilities. Though the company expected savings to total $4 million per year, the company later raised the estimates to $77 million over the next three years.“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. Our MA prior authorization protocols are routinely audited by CMS and we recently received a perfect score on an audit examining compliance with the 2024 final rule policies.”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.Insurers could be incentivized to not reverse prior authorization appeals because even a “relatively small increase” might hurt the health plan’s star ratings, a Humana presentation revealed.“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.”A CMS audit of Humana’s prior authorization decisions included no findings on post-acute care, the spokesperson added.CMS told Fierce Healthcare the agency appreciates and is reviewing the report."CMS continues to receive many inquiries about the use of prior authorization, and any additional changes to CMS policies would be proposed through rulemaking," a spokesperson said. "In addition, CMS sought comment and recommendations on enhancing MA data capabilities and increasing transparency, including on prior authorization."The feds have attempted to rein in prior authorization by enacting strict deadlines for payers and requiring utilization management committees to have a member with expertise in health equity. The agency anticipates new prior auth policies will improve the burden on patients, providers and payers to save the healthcare industry $15 billion over 10 years. They are conducting audits of major insurers' utilization management committees to determine whether health plans are following the law and meeting clinical coverage requirements. If CMS finds an insurer is non-compliant, it has the authority to issue notices and warning letters, requests for corrective action plans, enforcement letters, enrollment and marketing sanctions and civil monetary penalties.Federation of American Hospitals President and CEO Chip Kahn took the report’s release as an opportunity to swipe at MA insurers.“The report today puts an exclamation point on what we've been saying for a long time: patients are being hung out to dry by MA plans' delays and denials,” Kahn said in a statement. “It's past time that legislators and regulators hold plans accountable and protect patient care.”</div></body>

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UnitedHealth, CVS and Humana increasingly deploy AI and deny post-acute care claims, Senate report finds

The country’s three largest Medicare Advantage (MA) insurers obstruct seniors’ ability to receive post-acute care, a scathing report from the U.S. Senate Permanent Subcommittee on Investigations shows. It outlines attempts from UnitedHealthcare, CVS and Humana—which collectively cover nearly 60% of all MA enrollees—to use technology to reject prior...