Medicare Advantage’s prior authorization process has resulted in higher denial rates among three of the largest health insurance providers, whose use of predictive AI tools raises serious concerns about patient care, according to a new report issued by a Senate subcommittee on Thursday.

“[F]or beneficiaries of Medicare Advantage [prior authorization] has become not just a bureaucratic maze, but a potential threat to their health,” the report concludes.

Launched by the Permanent Subcommittee on Investigations (PSI) in spring, the report, “Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care,” aimed to examine barriers in accessing necessary health care, particularly after falls, strokes, and other health issues.

“The magnitude and scope of prior authorization requests and denials for particular types of care has been undisclosed before now. 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,” the report states.

The subcommittee analyzed over 280,000 documents from the three largest Medicare Advantage insurers, revealing alarming trends in how prior authorization is used. This process, intended to ensure that requested medical services are necessary, has turned into a bureaucratic obstacle that can endanger the health of seniors, the report concludes.

The top medical insurance providers – UnitedHealthcare, Humana, and CVS – were found to disproportionately deny prior authorization requests for post-acute care that may be critical for recovery after hospital stays. This can leave residents vulnerable to difficult health and financial decisions during recovery.

“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,” states the report.

Between 2019 and 2022, each of the top three insurers exhibited significantly higher denial rates for post-acute care compared to other types of medical care. For instance, in 2022, UnitedHealthcare and CVS denied requests for post-acute care at rates three times higher than their overall denial rates, while Humana’s denial rate for post-acute care was over 16 times higher than its average.

Moreover, these providers leaned excessively on the use of artificial intelligence (AI) tools and predictive technologies for the denials of care. UnitedHealthcare, for example, saw its denial rate for post-acute care rise dramatically over the years, coinciding with the implementation of automated systems designed to expedite the review process, the report notes. Internal documents indicated that this automation led to both faster reviews and a higher rate of adverse decisions, raising concerns about the accuracy and fairness of the process.

Also, the motivation for the denial of care was spurred by increasing profits. The findings suggest that these practices are not just bureaucratic inefficiencies but are intentionally designed to enhance profitability. CVS reported saving over $660 million in one year by denying inpatient facility admissions, and its prior authorization processes were adjusted to focus on maximizing denials. Humana, too, modified its templates to facilitate denial decisions.

The report suggests that the impact on patient care is very serious. These denial rates not only complicate access to necessary care but also lead to increased reliance on alternative, often less effective, care options. For example, during the pandemic, Humana temporarily relaxed some of its prior authorization requirements, revealing that such adjustments could lead to improved access when financial motives are not prioritized.

Insurance providers weigh in

In responding to requests for comment on the report, CVS told Skilled Nursing News that the subcommittee used documents that weren’t current, and that its prior authorization procedures, which are regularly audited by federal agencies, are in the clear.

“The report significantly misrepresents CVS Health’s use of prior authorization. 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,” a CVS spokesperson said in an emailed statement. “Our Medicare Advantage prior authorization protocols are routinely audited by the Centers for Medicare & Medicaid Services and we recently received a perfect score on an audit examining compliance with the 2024 Final Rule policies. We provided extensive feedback to the committee on these errors, which unfortunately were not addressed in the final report.”

Meanwhile, Humana also pushed back against the claims in the report, highlighting its favorable resident satisfaction rating and success with lower costs to patients as well as reduced rehospitalizations.

“This majority staff report mischaracterizes the Medicare Advantage program and our clinical practices, while ignoring CMS criteria demanding greater scrutiny around post-acute care,” a spokesperson for Humana said in an statement to SNN. “Compared to beneficiaries enrolled in Original Medicare, Medicare Advantage members experience 45% lower out-of-pocket costs and have more than a 40% lower rate of avoidable hospitalizations and report a 96% satisfaction rating – all at a lower cost to the Government.”

Nursing home advocates’ response

Nursing home advocacy groups said the report reaffirms their concerns with the MA prior authorization process.

“This report provides valuable substantiation of the concerns and issues we’ve shared repeatedly,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement. “Its data on denials of Medicare Advantage (MA) plans’ prior authorization requests for post-acute care occurring at rates far higher than other types of care, and the increase in the number of post-acute service requests that are subject to prior authorization, validate our nonprofit and mission-driven provider members’ experiences.”

Smith Sloan said that the MA plans’ tactics, which can range from initial denials based solely on AI algorithms to increased prior authorization requests and shorter approved care durations, jeopardize the wellbeing of residents.

“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,” she said.

And, Clif Porter, President & CEO of the American Health Care Association (AHCA), stressed that care decisions must be based on patient views and their medical team, not AI.

“This report should concern all of us because at the heart of it is the outright denial of care to seniors when they needed post-acute care the most,” said Porter. “Insurers and artificial intelligence should not determine if or how long a senior needs to recover in a skilled nursing facility—that’s a decision that should be made by the patient and their care team. We will continue to advocate that these plans be held accountable for unfair practices.”