Democratic Report Argues Medicare Advantage Plans Use AI To Reduce Post Acute Care
An incredibly biased report engineered by Sen. Richard Blumenthal, D-CT, finds that the country’s three largest Medicare Advantage (MA) insurers – United Healthcare, Humana, and Aetna — obstruct seniors’ ability to receive post-acute care. It says the companies use technology (perhaps AI algorithms) to reject prior authorization claims. The report finds that the three insurers denied claims for post-acute care at “far higher” rates than for other types of care. Humana’s denials in post-acute care were 16 times higher than its overall denial rates. UnitedHealthcare and CVS denials were three times higher.
I agree with the insurers that the report is sensationalistic. The report argues that at least two companies used AI and technology in denials. I do think a qualified professional should make the final clinical decision to deny a service.
But what is lost on the senator and the Centers for Medicare and Medicaid Servies (CMS) is that it is the proper role of managed care to scrutinize request for services. It stands to reason that inpatient coverage and post-acute care would be more scrutinized as they are very expensive. The comparison of denial rates of post-acute services to overall denials is simply ridiculous.
MA plans rightfully document savings against what is an unfettered fee-for-service (FFS) program. We should not apologize for that as the FFS system is uncontrolled and would bankrupt Medicare. Ironically, the report comes out just as a new CMS rule requires MA plans to follow the unfettered FFS program rules.
But the report is the latest sign that both CMS and Capitol Hill are coming after MA plans for major reforms.
Additional articles: https://www.fiercehealthcare.com/payers/unitedhealth-cvs-humana-increasingly-deploy-ai-and-deny-prior-auth-claims-senate-report
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#medicareadvantage #priorauthorization #providers
Elevance Health Reports Poor Q3 News
Like United Healthcare, Elevance Health underwhelmed investors when it reported its Q3 financial today. It did post $1 billion in profit but it has rising medical costs. The medical loss ratio (MLR) rose to 89.5% in the quarter. Medicaid’s mismatch between acuity and rates was blamed. Service entity Carelon reported a 15% rise in revenue. Medicaid membership has declined by 20% since the third quarter of 2023, but the company says Medicaid will be profitable in 2024. Elevance also reported its purchase of home and community service entity CareBridge.
Additional articles: https://www.modernhealthcare.com/insurance/elevance-health-earnings-shares-plummet-medicaid-unwinding and https://www.healthcaredive.com/news/elevance-q3-2024-earnings-lower-guidance-medicaid-challenges/730145/ and https://www.beckerspayer.com/payer/elevance-faces-unprecedented-medicaid-challenges-7-things-to-know.html and https://www.beckerspayer.com/payer/elevance-posts-1b-profit-in-q3-lowers-earnings-forecast.html
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#elevancehealth #medicareadvantage #medicaid #managedcare
https://www.modernhealthcare.com/insurance/elevance-health-medicare-advantage-star-ratings-2025
Bipartisan Group Of Lawmakers Want A Medicare Doc Fix
A bipartisan majority of House lawmakers want a Medicare doc fix included in the expected lame duck package in December. Such a bill would undo the 2.8% cut to Medicare pay for CY 2025 and address other long-standing problems with the current system. Likely, a partial or full rollback of the cut will occur, but no permanent fix will pass. Medicare payment rates have fallen by 29% over the last two decades when adjusting for the costs of running a practice.
Reading my blog that urges a permanent doc fix in Medicare: https://www.healthcarelabyrinth.com/docs-need-rate-relief-in-medicare-program/ .
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#medicare #providers #physicians #rates
— Marc S. Ryan
