“How could they make such a decision without ever coming to see me? said Sullivan, 76. “I still couldn’t walk without a physiotherapist behind me and another next to me. Were they all coming home with me?
UnitedHealthcare — the nation’s largest health insurance company, which offers Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. He owns NaviHealth, a care management company he purchased in 2020, and one of several companies that uses predictive technology. has help insurance companies make coverage decisions.
Its proprietary “NH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, pre-existing health conditions and other factors. Based on these comparisons, an algorithm anticipates what type of care certain patients will need and for how long.
But patients, providers and patient advocates in several states said they noticed a suspicious coincidence: The tool often predicts a patient’s discharge date that coincides with the date their insurer ends coverage, even if the patient needs additional treatment than government-run Medicare. would provide.
“When an algorithm doesn’t fully consider a patient’s needs, there’s a glaring disconnect,” said Rajeev Kumar, a physician and president-elect of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care. practitioners. “That’s where human intervention comes in.”
The federal government will try to level the playing field next year, when the Centers for Medicare and Medicaid Services begins restricting how Medicare Advantage plans use predictive technology tools to make certain coverage decisions. (New rules also repress on misleading advertising of plans.)
A bill for $10,000 for 18 days of care
Medicare Advantage plans, an alternative to the original government-run Medicare program, are managed by private insurance companies. About half of people eligible for comprehensive Medicare benefits are enrolled in private plans, attracted by their lower costs and improved benefits like dental care, hearing aids, and non-medical extras like transportation and home-delivered meals. But plans must still meet Medicare’s coverage criteria and cannot deny benefits covered by Original Medicare.
Insurers receive a monthly payment from the federal government for each insured person, regardless of the level of care they need. According to the Inspector General of the Department of Health and Human Services, this arrangement “potentially incentivizes insurers to deny access to services and payment in an effort to increase their profits.” Nursing home care is one of the most often refused services through private plans — something that original Medicare would likely cover, investigators found.
After UHC discontinued its nursing home coverage, Sullivan’s medical team agreed with her that she was not ready to go home and provided her with an additional 18 days of treatment. His bill came to $10,406.36.
Beyond her mobility issues, “she also had a surgical wound that required daily dressing changes” when UHC stopped paying for her nursing home care, said Debra Samorajczyk, a registered nurse and administrator at Bishop Wicke Health & Rehabilitation Center, the facility that treated Sullivan.
Sullivan’s notice of denial of coverage and the NH Predict report did not mention wound care or his inability to climb stairs. Medicare most likely would have covered his ongoing care, Samorajczyk said.
Sullivan appealed twice but lost. She plans to appeal to the next level, the Medicare Appeals Council, the last step before the case could be heard in federal court.
Sullivan’s experience is not unique. In February, Ken Drost’s Medicare Advantage plan, provided by Security Health Plan of Wisconsin, wanted to reduce its coverage at a Wisconsin nursing home after 16 days, the same number of days NaviHealth had predicted. But Drost, 88, who was recovering from hip surgery, needed help getting up and walking. He remained at the nursing home for an additional week, at a cost of $2,624.
After appealing twice and losing, his hearing on his third appeal was about to begin when his insurer agreed to pay his bill, said his attorney, Christine Huberty, supervising attorney at the Greater Wisconsin Agency on Aging Resources Elder Law & Advocacy Center in Madison. .
Systematic reductions in retirement home stays
“Advantage plans consistently reduce patient stays in nursing homes,” she said, including Humana, Aetna, Security Health Plan and UnitedHealthcare. “In all cases, we find that their treating medical providers do not agree with the denials. »
UnitedHealthcare and NaviHealth declined interview requests and did not respond to detailed questions about why Sullivan’s nursing home coverage was discontinued over the objections of his medical team.
Aaron Albright, a NaviHealth spokesperson, said in a statement that the NH Predict algorithm is not used to make coverage decisions and is instead intended “to assist the member and facility in developing personalized discharge planning post-acute care. Length of stay forecasts “are estimates only.”
However, NaviHealth’s website boasts that the company’s “predictive technology and decision support platform” ensures that “patients can enjoy more days at home, and health care providers Health and health plans can significantly reduce care-specific costs and unnecessary readmissions.”
New federal rules for Medicare Advantage plans starting January 1, they will limit their use of algorithms in coverage decisions. Insurance companies using such tools will “ensure that they determine medical necessity based on the specific individual’s circumstances,” the requirements state, “instead of using an algorithm or software that does not does not take into account the situation of an individual. .”
And before denying coverage deemed not medically necessary, another change requires that a denial of coverage “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care.” health that is appropriate for the service in question.
Jennifer Kochiss, a social worker at Bishop Wicke who helps residents appeal their insurance, said the new requirement would fill “a big hole.”
In a statement, UHC spokesperson Heather Soule said the company’s current practices are “compliant” with the new rules. “Medical directors or other appropriate clinical personnel, not technology tools, make all final decisions on adverse medical necessity” before coverage is denied or discontinued.
David Lipschutz, associate director of the Center for Medicare Advocacy, questions how CMS will enforce the rules, which do not include specific penalties for violations.
Meena Seshamani, CMS deputy administrator and Medicare program director, said the agency will conduct audits to verify compliance with all the new requirements and will “consider issuing enforcement action, such as a civil fine or registration suspension, in the event of non-compliance.”
KFF Health Newsformerly known as Kaiser Health News or KHN, is a national newsroom that produces in-depth journalism on health issues and is one of KFF’s primary operating programs.
