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This audio is auto-generated. Please let us know if you have feedback<\/a>.<\/p>\n Dive Brief:<\/p>\n Medicare Advantage plans deny post-acute care on a daily or weekly basis for members in a majority of nursing homes \u2014 often against the advice of medical professionals, according to a new survey from the American Health Care Association. Dive Insight:<\/p>\n In MA, the privately run alternative to Medicare, the government pays insurers to manage seniors\u2019 care. The plans can offer a greater range of benefits than in traditional Medicare, such as dental, vision and hearing care along with other add-ons like gym or transportation stipends. However, MA insurers can also put roadblocks to care in place that aren\u2019t allowed in its sister program.<\/p>\n Research has found that MA plans\u2019 utilization management practices, like prior authorizations, harm care access and are frequently overturned upon appeal<\/a>, exacerbating worries that MA plans might be using the processes to avoid paying for necessary medical care.<\/p>\n Payers\u2019 use of artificial intelligence in coverage determinations is also a cause for concern, given the tools\u2019 propensity to make mistakes that, in this area, can have serious consequences for patients.<\/p>\n The three largest MA payers \u2014\u00a0UnitedHealthcare, Humana and CVS \u2014 intentionally used algorithms to significantly increase claims denials<\/a> for MA beneficiaries between 2019 and 2022, according to a Senate investigation published last year.<\/p>\n The AHCA\u2019s survey provides new data to one area of that debate: post-acute care, which helps patients recover after an illness or injury. Along with information about the frequency of denials for MA beneficiaries, the survey found more than two-thirds of nursing homes had a situation wherein an MA plan pulled coverage for a resident against medical advice.<\/p>\n More than half of providers said such denials were frequently overturned upon appeal, suggesting the initial denial was should have been approved in the first place.<\/p>\n \u201cOften, we see a resident\u2019s stay cut short prematurely, leaving them with a tough decision to make. Pay out of pocket, or discharge home with the risk of ending up back in the hospital. It makes our job extremely challenging,\u201d one provider wrote in response to the survey.<\/p>\n The AHCA\u2019s findings align with the Senate investigation last year, which found UnitedHealthcare, Humana and CVS denied prior authorization requests for post-acute care at \u201cfar higher rates\u201d than other services.<\/p>\n \u201cThis constant hoop jumping is resulting in too many skilled nursing patients being discharged too soon against medical advice, threatening their recovery,\u201d\u00a0Clif Porter, the president and CEO of AHCA, said in a statement. \u201cWe want to make sure Medicare Advantage plans are providing the therapy benefits our seniors were promised and are not leaving important \u2014 sometimes life-saving \u2014 medical decisions to AI or insurers without appropriate guardrails and oversight.\u201d<\/p>\n The issue is increasing importance as more seniors select MA. Currently,\u00a0more than half of Medicare beneficiaries \u2014 some 35 million people<\/a>\u00a0\u2014 are in the program, according to government data. That share is expected to continue rising.<\/a><\/p>\n MA plans generally deny allegations that they stymie necessary medical care, and defend prior authorizations as an important tool to keep a lid on skyrocketing costs. Still, amid growing public attention to care delays and denials,\u00a0major insurers pledged to reform the processes earlier this summer<\/a>, including reducing what types of care are subject to prior authorizations.<\/p>\n","protected":false},"excerpt":{"rendered":"Listen to the article 4 min This audio is auto-generated. 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\nThe AHCA, which represents nursing homes, assisted living communities and other providers for elderly and disabled individuals, surveyed more than 360 nursing home providers<\/a> in May and found that 37% said post-acute care is delayed or denied at least once a week. Another 29% said such decisions come as frequently as every day.
\nThe findings build on other research suggesting MA plans aggressively restrict care, which critics argue is done to increase their profits. UnitedHealth, the parent company of the largest MA insurer in the U.S., is currently being investigated by lawmakers<\/a> for potentially impeding care for residents of nursing homes.
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