A Senate report published Thursday blasts the nation’s three largest Medicare Advantage insurers for increasingly limiting access to post-acute care and forcing vulnerable patients into “impossible choices” in order to protect profits.
“Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care” examined data and internal documents from UnitedHealthcare, Humana and CVS to better understand how the big three use prior authorization as a cost-cutting tool. It investigated a range of post-acute placements, but reduced access to skilled nursing facilities is called out perhaps most extensively in the 54-page report.
“This Majority staff report reveals how Medicare Advantage insurers are intentionally using prior authorization to boost profits by targeting costly yet critical stays in post-acute care facilities,” read the findings from the Permanent Subcommittee on Investigations. They claim to offer a broad scope of new denial information that has been missing from MA policymaking conversations. “Insurer denials at these facilities, which help people recover from injuries and illnesses, can force seniors to make difficult choices about their health and finances in the vulnerable days after exiting a hospital.”
Denials also are used to shorten lengths of a stay at a nursing home, inpatient rehabilitation facility or long-term acute care hospitals, a practice members of Congress have previously accused of undermining the doctor-patient relationship — and, ultimately, patient outcomes. Nursing home patients often don’t appeal MA denials because they are faced with potentially steep out-of-pocket costs for any extra time spent in a facility in the case of a decision that isn’t overturned, provider groups and consumer advocates have said.
The subcommittee found that, between 2019 and 2022, UnitedHealthcare, Humana, and CVS each denied prior authorization requests for post-acute care “at far higher rates than they did for other types of care, resulting in diminished access to post-acute care for Medicare Advantage beneficiaries.”
A 9-times increase in SNF denials
When it came to skilled nursing facilities, UnitedHealthcare’s denial rate increased ninefold between 2019 and 2022. UnitedHealthcare also processed far more home health service authorizations for Medicare Advantage members during the same time period, underscoring concerns about insurers rejecting placements in post-acute care facilities in favor of less costly alternatives, the report said.
Skilled nursing providers have frequently complained that their patients are being pushed into home care before their doctors determine they’re ready for it; those concerns have grown as Medicare Advantage plans came to represent more than half of all Medicare beneficiaries last year.
The Centers for Medicare & Medicaid Services has in the last two years added additional requirements for MA plans to try to rein in the growing use of prior authorization.
LeadingAge earlier this month asked CMS to strengthen a new data collection effort that could help determine if MA plans are conforming to policy clarifications issued for calendar year 2024 — and whether the data collection could serve as an enforcement tool that helps ensure patient access.
The provider group wants CMS to expand its data collection beyond initial prior authorizations to determine how and how often insurers use concurrent reviews and re-authorizations as “barriers to access.”
“The plans’ behaviors revealed in this report, including their avoidance of provider engagement by instructing employees to withhold information on authorization decision-making and by restricting communication to online portals, as well as their strategic, deliberate decisions to grant or deny prior-authorization requests, cannot and should not continue,” LeadingAge President and CEO Katie Smith Sloan said in a statement after seeing the “explosive” report.
“This deliberate denial of necessary and timely care harms the MA plan beneficiaries our nonprofit and mission-driven provider members serve and also threatens our members’ viability,” she added.
Expanding savings at what cost?
The report authors outline specific strategies they say insurers have taken to ensure denials remain a core part of their business strategy with internal tools, including predictive algorithms, and trying to minimize appeals and overturned decisions.
In 2019, for instance, UnitedHealthcare issued an initial denial to 1.4% of requests for admission to skilled nursing facilities. But in 2022 — the first full year in which naviHealth was managing denials using its nH Predict tool — the insurer denied 12.6% of such requests, or nine times more than before.
That type of tool, in particular, has drawn wide-ranging scorn and at least two class action lawsuits from former skilled nursing patients. Others in Congress have previously called on CMS to outright ban the use of AI in coverage determinations.
When CVS in 2021 deployed its “Post-Acute Analytics” tool, which used artificial intelligence with the aim of reducing spending on skilled nursing stays, the company expected to save about $4 million annually. Within seven months, however, the company projected that a more aggressive, expanded use of the initiative could save $77 million over the next three years.
“Documents reveal that CVS saw a consistent correlation between increasing prior authorization requirements and expanding savings,” the report said, adding that CVS once considered “deprioritizing” prior authorizations but concluded the lost savings would be “too large to move forward” with.
In light of its findings, the subcommittee called on CMS to:
- Begin collecting prior authorization information broken down by service category.
- Conduct targeted audits if insurer prior authorization data reveals notable increases in adverse determination rates.
- Expand regulations for insurers’ utilization management committees to ensure that predictive technologies do not have undue influence on human reviewers.
Sen. Richard Blumenthal (D-CT), the subcommittee’s chairman, took to Twitter Thursday to publicize the findings and push for action.
“Our intensive investigation shows the deep disadvantages & dangers in Medicare Advantage for seniors, often outweighing the advertised advantages,” he said. “In fact, despite alarm & criticism in recent years about abuses & excesses, insurers have continued to deny care to vulnerable seniors — simply to make more money.”
The report also emphasized recent analyses that show MA is actually costing the government more, as much as 22% more, than traditional Medicare.
Although the subcommittee’s work is intended to spark regulatory reform, the authors also noted insurers “using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices” should be on alert.
“There is a role for the free market to improve the delivery of healthcare to America’s seniors, but there is nothing inevitable about the harms done by the current arrangement,” authors wrote. “Insurers can and must do better, for the sake of the American healthcare system and the patients the government entrusts to them.”
