StSenators warned the country’s largest Medicare Advantage insurers in a hearing Wednesday that they must abide by Medicares coverage rules and cannot rely on algorithms to deny patients the care they need.
Congress is also stepping up its oversight. Lawmakers on both sides have asked UnitedHealth Group, Humana and CVS Healths Aetna for internal documents that will show how decisions are made to grant or deny access to care, including how they are using [artificial intelligence]Sen. Richard Blumenthal, the top Democrat on a subcommittee with the power to investigate government affairs, said at the hearing.
I want to warn these companies, Blumenthal (D-Conn.) said. If you deny lifesaving coverage to the elderly, we stand by. We will expose you. We will ask for better. We will pass legislation as needed. But action will be imminent.
The hearing comes on the heels of a STAT investigation that found Medicare Advantage insurers routinely rely on proprietary algorithms as a basis for denying care. Instead of using technology to guide Medicare patient care in a nursing home or rehabilitation facility, many Medicare Advantage plans use it as a hard rule to avoid paying for care and to send patients home as soon as possible. possible even if the patients are not ready.
Patients often have no idea that an algorithm is being used in the denial process and face thousands of dollars in costs if they decide to pay for treatment themselves. Plus, if they and their families decide to appeal a denial, they could be trapped in weeks, months, or even years of paperwork and red tape.
UnitedHealth confirmed receipt of a letter but declined to comment further. Humana and CVS did not immediately respond to STAT’s questions.
Christine Huberty, a Wisconsin attorney who provides free legal aid to Medicare beneficiaries and who has been quoted in the STAT story, testified Wednesday that there has been a deluge of algorithmically generated denials of Medicare Advantage plans.
Our agency has been overwhelmed with these cases to the point that we have started pushing them away, Huberty said. He added that the denial and appeals process is a maze of bureaucracy pitting sick and injured seniors against an impossible system.
The waste usually comes from third-party companies that either contract with insurers or are now owned by insurers, such as NaviHealth. Gloria Bent, another witness at the hearing, ran into a NaviHealth denial with her husband, Gary, who was insured under a Medicare Advantage plan and recently died after his melanoma returned.
Gary underwent surgery to remove a lesion on his brain and came away with significant mobility and cognitive impairments, Bent said. His neurosurgeon recommended intensive rehabilitation services, nursing care, and therapy, but NaviHealth denied those services and instead moved Gary to a short-term facility.
A NaviHealth Care Coordinator then called Bent and told her her husband would be discharged in just over two weeks. The coordinator strongly suggested that they consider he would be permanently wheelchair-bound, and therefore highly recommended a self-paid, skilled nursing facility, Bent said in her testimony. And if I lived in a house that was not handicapped accessible, which ours was not, then I had to move.
This shouldn’t happen to families and patients. It’s cruel, Bent said. Why do people who look at patients only on paper or through the lens of an algorithm make decisions that deny services judged necessary by healthcare professionals who know their patients?
Although the senators who appeared at the hearing agreed that Medicare Advantage denials are a problem, especially for people facing serious illness and injury, they didn’t necessarily agree on a solution.
The federal agency that oversees Medicare issued new regulations in April that Medicare Advantage plans must ensure they are making medical need determinations based on the specific individual’s circumstances instead of using an algorithm or software that ignores the individual circumstances, the regulatory status. However, Blumenthal was concerned that insurers were already struggling to comply with existing Medicare coverage laws.
A new rule is only good if they’re willing to change their real-world practices, Blumenthal said.
Despite the prevalence of algorithms used in the denial of care process, Republicans didn’t seem eager to get hands-on with how Medicare Advantage plans work. Sen. Ron Johnson, the subcommittee’s top Republican, echoed the arguments that health insurance companies often espouse, namely that hampering insurers’ ability to manage care will force them to cut benefits or raise premiums. Johnson warned that if Congress limits the ability of Medicare Advantage plans to issue preemptive authorizations and deny care, it would come at a cost.
Either the cost to the payer could go up quite dramatically, or Medicare Advantage plans would have to cut back in terms of [the supplemental benefits] they cover, Johnson said. I think these are two of the most likely scenarios, right?
I would argue that both of those things would have happened, said Lisa Grabert, a professor of health care at Marquette University and a former Republican aide to Congress.
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