Washington, D.C. – Yesterday, the U.S. Senate Permanent Subcommittee on Investigations (PSI) released a
Majority Staff Report that found the three largest Medicare Advantage (MA) insurers denied prior authorizations for post-acute care at rates far higher than other types of care. The impact is that hundreds of thousands of beneficiaries who needed medically appropriate post-acute care were denied access to this critical care during the prior authorization process. The denials came, in large part, due to advanced technology systems that used artificial intelligence to flag costly coverage requests and minimize the approved coverage or, ultimately, deny the claim altogether.
“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 Clif Porter, President & CEO of the American Health Care Association (AHCA). “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.”
The PSI report looked at the three largest Medicare Advantage insurers: UnitedHealthcare, Humana, and CVS, and found that denial rates for post-acute care at each insurer increased dramatically and disproportionately between 2019 and 2022, resulting in limited access to post-acute care for beneficiaries:
“Insurers are intentionally using prior authorization to boost profits by targeting costly yet critical stays in post-acute care facilities. Insurer denials at these facilities, which help people recover from injuries and illnesses, can for seniors to make difficult choices about their health and finances in the vulnerable days after exiting a hospital.”
“Insurers should recognize the value of post-acute care,” added Porter. “When patients receive therapy in a skilled nursing facility after a hospital stay, they often return home. Rehabilitation therapy can help prevent future rehospitalizations, falls, or other detrimental, costly outcomes. For Medicare Advantage to deliver on its promise to America’s seniors, post-acute care must be part of the package.”
PSI made recommendations in the report regarding oversight and regulatory interventions in an effort to ensure medical claims are properly reviewed and that any notable increases in denials are properly audited.
The report was covered by multiple outlets, including
Modern Healthcare,
Stat News,
Axios,
Politico Pro, and others.