Denied by AI: Medicare Advantage ‘Predictive’ Software Disrupts Care, Feds Say | BenefitsPRO

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Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she received surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to return home.

At the time, she couldn’t walk more than a few feet even with help, let alone climb the stairs to the front door, she said. She still needed help using a colostomy bag after major surgery.

How could they make a decision like that without ever coming to see me? said Sullivan, 76. I still couldn’t walk without a physical therapist behind me and another at my side. Were they all coming home with me?

UnitedHealthcare, the nation’s largest health insurer, which offers Sullivan’s Medicare Advantage plan, doesn’t have a crystal ball. It owns naviHealth, a care management company acquired by UHC sister company Optum in 2020. Both are part of UnitedHealth Group. NaviHealth analyzes data to help UHC and other insurance companies make coverage decisions.

Its proprietary nH Predict tool analyzes millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions and other factors. Based on these comparisons, an algorithm anticipates what type of care a specific patient 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, which coincides with the date their insurer cuts coverage, even if the patient needs additional treatment. that government- run Medicare would provide.

When an algorithm doesn’t fully consider a patient’s needs, there’s a glaring mismatch, said Rajeev Kumar, a physician and president-elect of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care professionals. 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 some coverage decisions. `

Medicare Advantage plans, an alternative to the government-run original Medicare program, are operated by private insurers. About half of the people eligible for full Medicare benefits are enrolled in private plans, attracted by their lower costs and added benefits such as dental care, hearing aids and a host of non-medical extras such as transportation and home-delivered meals.

Insurers receive a monthly payment from the federal government for each enrollee, regardless of how much care they need. According to the inspector general of the Department of Health and Human Services, this agreement increases the potential incentive for insurers to deny access to services and payment in an attempt to increase profits. Nursing home care has been among the services most frequently denied by private plans, something that original Medicare would likely cover, researchers found.

After UHC cut her nursing home coverage, Sullivan’s medical team agreed with her that she was not ready to go home and provided an additional 18 days of treatment. Her bill came to $10,406.36.

In addition to mobility issues, she also had a surgical wound that required daily dressing changes when UHC stopped paying for her care at the nursing home, said Debra Samorajczyk, a registered nurse and administrator at Bishop Wicke Health and Rehabilitation Center, the facility that treated Sullivan. .

Sullivan’s coverage denial notice and the NH Predict report made no mention of wound treatment or his inability to climb stairs. Original Medicare likely would have covered her ongoing care, Samorajczyk said.

Sullivan appealed twice but lost. Your next appeal was heard by an administrative law judge, who holds a court-style hearing, usually by telephone or videoconference, at which all parties can give testimony. UHC refused to send a representative, but the judge still sided with the company. Sullivan is considering appealing to the next level, the Medicare Appeals Board, and the final step before the case can be heard in federal court.

Sullivans’ experience is not unique. In February, Ken Drost’s Medicare Advantage plan, provided by Security Health Plan of Wisconsin, wanted to cut his coverage at a Wisconsin nursing home after 16 days, the same number of days naviHealth predicted would be needed. But Drost, 87, who was recovering from hip surgery, needed help getting out of bed and walking. He stayed in the nursing home for another week, at a cost of $2,624.

After he appealed twice and lost, his hearing on his third appeal was about to begin when his insurance company 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.

Advantage plans routinely reduce patients’ length of stay in nursing homes, she said, including Humana, Aetna, Security Health Plan and UnitedHealthcare. In every case, we see that medical care providers disagree with the denials.

UnitedHealthcare and naviHealth declined interview requests and did not respond to detailed questions about why Sullivan’s nursing home coverage was stopped over the objections of his medical team.

Aaron Albright, a spokesman for naviHealth, said in a statement that the nH Predict algorithm is not used to make coverage decisions and is instead intended to help the member and facility develop personalized discharge care planning. post-treble. Length of stay forecasts are estimates only.

However, the naviHealths website prides itself on saving plans money by restricting care. The company’s predictive technology and decision support platform ensure that patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce the specific costs of unnecessary care and readmissions.

New federal rules for Medicare Advantage plans, starting in January, will control the use of algorithms in coverage decisions. Insurers using such tools are expected to ensure they are making determinations of medical necessity based on the specific individual’s circumstances, the requirements say, rather than using an algorithm or software that does not take into account an individual’s circumstances.

The CMS-required notices that nursing home residents now receive when a plan cuts their coverage may be eerily similar, although they lack details about a particular resident. Sullivan’s notice from UHC contains language identical to what Drost received from his Wisconsin plan. Both say, for example, that the plan’s medical director reviewed their cases, without providing the director’s name or medical specialty. Both omit any mention of their health conditions that make management at home difficult, if not impossible.

Tools must still meet Medicare coverage criteria and cannot deny benefits covered by original Medicare. If insurers believe the criteria are too vague, plans can base the algorithms on their own criteria as long as they disclose the medical evidence supporting the algorithms.

And before denying coverage deemed not medically necessary, another change requires that a denial of coverage be reviewed by a physician or other appropriate health care professional with experience in the area of ​​medicine or health care that is appropriate for the service in question.

Jennifer Kochiss, a Bishop Wicke social worker who helps residents file insurance appeals, said patients and providers have no say in whether the doctor reviewing a case has experience with the client’s diagnosis. The new requirement will close a big hole, she said.

Major MA plans oppose the changes in comments submitted to CMS. Tim Noel, UHC CEO for Medicare and Retirement, said the ability of MA plans to manage beneficiary care is necessary to ensure access to safe, high-quality care and maintain high member satisfaction, while also managing appropriately the costs.

Restricting the use of management tools would deviate markedly from Congress’s intent in creating Medicare managed care because it substantially limits the ability of MA plans to actually manage care, he said.

In a statement, UHC spokeswoman Heather Soule said the company’s current practices are consistent with the new rules. Medical directors or other appropriate clinical personnel, not technology tools, make all final determinations of adverse medical necessity before coverage is denied or discontinued. However, these medical professionals work for UHC and generally do not examine patients. Other insurers follow the same practice.

David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS will enforce the rules, as it does not mention specific penalties for violations.

CMS Deputy Administrator and Medicare Program Director Meena Seshamani said the agency will conduct audits to verify compliance with the new requirements and will consider issuing enforcement action, such as a civil fine or enrollment suspension, for those who do not. -conformity.

Although Sullivan remained at Bishop Wicke after UHC stopped paying, she said another resident went home when his MA plan no longer paid. After two days at home, the woman fell and an ambulance took her to the hospital, Sullivan said. She was back in the nursing home because they kicked her out before she was ready.

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