As a Senate subcommittee continues to seek additional information on Medicare Advantage care denials through May, nursing home advocacy groups have issued detailed recommendations that underline lack of transparency, administrative burdens and low reimbursements associated with MA plans.
The Senate Homeland Security & Government Affairs Permanent Subcommittee on Investigations held a hearing on Wednesday that raised alarms on MA plans’ frequent denial of care of medically necessary procedures and services. The subcommittee also stressed the over reliance on Artificial Intelligence (AI) tools in place of more personalized, physician-based means of determining coverage.
Led by senators Richard Blumenthal (D-Conn.) and Ron Johnson (R-Wis.), the subcommittee intends to get a close up look at the MA plans’ denial process for corrective measures.
“Insurers are, in effect, denying Americans necessary care in order to fatten and pad their bottom lines, and that phenomenon is unacceptable,” said Sen. Blumenthal. “I want to put these companies on notice. If you deny life-saving coverage to seniors, we are watching, we will expose you, we will demand better, we will pass legislation, if necessary,” he said.
The Senate subcommittee noted that currently, insurance providers of MA plans were not being held accountable for the denials because there was insufficient data collected from them.
To that end, the subcommittee sent letters to some of the largest MA insurers – CVS-Aetna, United Heath and Humana – which together cover more than 50% of Medicare Advantage beneficiaries. These insurers are being requested to share internal documents that may in turn shed light on their process of MA coverage determination.
The subcommittee concluded that greater scrutiny and oversight of MA plans was in order, especially as post-acute care seems to get most frequently denied amid MA plans’ gross margins consistently remaining higher than any other insurance product.
MA enrollment is currently over 50%, and has been exerting a strain on skilled nursing facilities (SNFs).
Meanwhile, MA plans routinely deny SNF care for beneficiaries without looking at medical records, according to patient advocates who spoke to the subcommittee.
Christine Jensen Huberty, an attorney with the Greater Wisconsin Agency on Aging Resources, told the subcommittee that decisions on coverage weren’t being made by patients’ doctors, but others who at times even lacked knowledge of SNF care.
Legislators and experts also noted the problematic use of AI tools and algorithms for prior authorizations – and denial based on incorrect assessment of patient needs, especially when MA plan insurers hire third party contractors.
Members of LeadingAge, which issued a detailed letter Thursday to aid the subcommittee’s work, have noted that these tools use “generalized data” to determine care without ever having examined the patient. In the end, this means patient care is inappropriately denied or cut short.
Leaders at LeadingAge, which represents more than 5,000 non-profit aging services providers, said that even as MA plans gain market share, they are reimbursing with “inadequate rates” for services performed, jeopardizing access to care while adding to administrative burdens for SNFs during the prior authorization phase.
“MA plan contracts increasingly pay SNFs and [Home Health] providers 60-80% of Medicare Fee for Service (FFS) rates while also reducing the number of days of services,” wrote Nicole Fallon, vice president of Integrated Services & Managed Care at LeadingAge, in her letter to the Senate subcommittee and shared with SNN. “Simultaneously, MA plans processes impose significant … administrative burden on providers through laborious and frequent prior authorizations.”
In the letter, LeadingAge outlined through examples of resident situations the inappropriate denials of service or quicker discharges with grave consequences for the residents. Altogether, beneficiary access to Medicare services when enrolled in an MA plan is “threatened,” the letter concludes.
LeadingAge noted in the letter that patient service denials were based on narrowly defined parameters such as the ability to ambulate more than 50 to 100 feet, even if the patients had feeding tubes, head bleeds or cognitive challenges.
Moreover, LeadingAge officials said AI tools shrouded the process of denial of coverage.
“Transparency in how plans make coverage determinations is essential to ensure plans meet Medicare coverage requirements and deliver equitable access to Medicare services. These algorithms … are a black box,” said Fallon. “Members also tell us that it is not clear where the third-party contractors obtain some of their data on the patients especially related to cognition because the provider does not submit [it],” she said.
American Health Care Association/National Center for Assisted Living (AHCA/NCAL) also decried the lack of transparency in the MA coverage decision process.
“Skilled nursing providers have and continue to struggle with opaque, unclear Medicare Advantage coverage decisions or decisions established solely by algorithms that are not transparent and inconsistent with traditional Medicare criteria or national and/or local coverage determinations,” AHCA/NCAL said in an emailed statement to SNN. “The process is administratively burdensome, confusing, and a barrier to care. It has been exacerbated by a practice that is becoming more and more common — the delegation to external third parties.”
Officials for AHCA/NCAL expressed hope that change may be coming.
“We are hopeful that the Medicare Advantage rule recently finalized by CMS, which addresses some of these practices, will be implemented effectively and hold plans accountable for inappropriate practices,” the AHCA statement said.
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