Federal investigators have highlighted concerns over private Medicare Advantage plans denying short-term nursing home or inpatient rehabilitation services. Their reports indicate significant issues with patient care denial.
Two reports reveal that prominent insurers selling Medicare Advantage plans have denied around 13% of patient requests for skilled nursing facilities. These refusals occur when patients need recovery after surgery or severe illnesses, according to findings.
The investigation relates to plans covering approximately 35 million elderly Americans under the federal Medicare program. Criticism has been directed at these plans for delays and refusals of medically required treatments.
Insurers often demand prior authorizations before covering services. These Medicare Advantage plans receive fixed payments to manage patient care, motivating them to reduce expenses. Consequently, they often deny costly inpatient care like specialized rehabilitation, opting for outpatient facilities or home settings.
The reports from the Department of Health and Human Services’ inspector general focus on UnitedHealth Group, Humana, and CVS Health. These major companies collectively cover most Medicare Advantage enrollees. The first report shows they denied 13% of requests for continued recovery in skilled nursing facilities.
Investigators express concerns over supervision of external contractors deciding on specialized care eligibility.
“The dominance of a few large insurance companies in Medicare Advantage and the use of contractors to process prior authorization requests means that the policies and performance of just a few companies can impact care for millions of people,” said Rosemary Bartholomew.
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