The recent practices of major Medicare Advantage (MA) insurers, including UnitedHealthcare, CVS, and Humana, have raised concerns, according to a report from the U.S. Senate Permanent Subcommittee on Investigations.
The report alleges that these companies have been using technology, such as artificial intelligence, to deny prior authorization claims for post-acute care, potentially obstructing seniors' access to necessary medical services. The denial rates for post-acute care claims were reported to be significantly higher than for other types of care.
Between 2019 and 2022, Humana's denial rates for post-acute care were 16 times higher than its overall denial rates, while UnitedHealthcare and CVS reported denial rates three times higher. The report suggests that these practices may be driven by profit motives, with insurers denying care to vulnerable seniors while expanding their automated processes for claims decisions.
The report also raises concerns about the implications of using artificial intelligence in healthcare decision-making, as there appears to be a correlation between the adoption of automated systems and an increase in denial rates. The report highlights the role of medical professionals in the approval process and the potential pressure they may face to conform to AI recommendations.
The report also mentions Humana's partnership with naviHealth, a company involved in prior authorization processes, and how this further complicates the landscape for healthcare providers seeking approvals for necessary treatments.
The Centers for Medicare & Medicaid Services (CMS) is reviewing the report's findings, indicating a potential shift in regulatory oversight. In response to concerns, CMS has enacted strict deadlines for payers and mandated that utilization management committees include members with expertise in health equity.
The report has prompted calls for increased regulation of insurers' internal prior authorization committees and greater transparency and accountability. Industry leaders have reacted strongly to the report, with some criticizing MA insurers for delays and denials that leave patients vulnerable.
Insurers like UnitedHealthcare and CVS have defended their practices, claiming that the report mischaracterizes their use of prior authorization and pointing to compliance with CMS audits. The implications of these findings could lead to significant changes in how Medicare Advantage insurers operate, as regulators and lawmakers increase scrutiny. The ongoing dialogue surrounding these issues will be critical in shaping the future of patient care and access to necessary medical services.