Category Archives: Abuse

New Senate Report on Prior Authorization in Medicare Advantage Begs a Question: Can Big Insurance Ever Be Regulated Adequately to Ensure Patient Care?

Posted on by • Posted in Abuse, Artificial Intelligence, Fraud and Abuse, Health Insurance Denial, Health Insurance Industry, Healthcare Reform, Lobbyist, Medicare Advantage, Medicare Advantage Denials, Prior Authorization, Profit, Profit Motive • Leave a comment
https://healthcareuncovered.substack.com/p/new-senate-report-on-prior-authorization?utm_source=post-email-title&publication_id=255152&post_id=150665002&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true

Last week, the Senate Permanent Subcommittee on Investigations, led by Sen. Richard Blumenthal (D-Connecticut), released a Majority Staff Report on rampant prior authorization (PA) abuses in Medicare Advantage (MA).

The report offers unique insight into recent trends in the use of prior authorization by Medicare Advantage plans and the strategy and motives behind insurance corporations’ use of it. 

While the findings won’t surprise those who’ve been following health policy trends, it is immensely concerning that between 2019 and 2022, the prior authorization denial rate for post-acute care in UnitedHealth’s Medicare Advantage plans doubled.

The denial rate for long-term acute care hospitals in Humana’s Medicare Advantage plans increased by 54% from 2020 to 2022. During this time, UnitedHealth, CVS/Aetna, and Humana increased their use of artificial intelligence (AI) for prior authorization reviews, often resulting in increasing denial numbers and decreasing (or absent) review time by human beings.

The report recommends that the Centers for Medicare and Medicaid Services (CMS) collect additional data, conduct audits of prior authorization processes, and expand regulations on the use of technology in PA reviews. While these recommendations would be positive steps, the report’s findings call into question whether Big Insurance can ever be trusted or regulated enough to prevent abuse of patients through prior authorization and other mechanisms. 

This report provides an in-depth look at insurers’ motivations. Sadly, those motivations are not to “make sure a service or prescription is a clinically appropriate option,” as UnitedHealth claims, but to decrease the amount spent on medical care to increase the corporations’ profits.

The report noted that CVS, which owns Aetna, saved $660 million in 2018 by denying Medicare Advantage patients’ claims for treatment at inpatient facilities. Around the same time, CVS found in its testing of a model to “maximize approvals,” which would be a good thing for patients, that the model jeopardized profits because it would lead to more care being covered. In 2022, CVS “deprioritized” a plan to increase auto-approvals because of the lost “savings” from denying patient care. 

The report found that the motivation to increase profits, without regard for patient care, was not unique to CVS/Aetna.

UnitedHealth’s naviHealth subsidiary provided this directive to its employees: “IMPORTANT: Do NOT guide providers or give providers answers to the questions” when speaking to a patient’s doctor about a prior authorization request. Instead of working collaboratively with doctors to get patients the care they need, UnitedHealth told its workers not to bother. In a training session offered to Humana employees involved in prior authorization reviews, the company explained that reviewers should deny a request for post-acute care even if a patient needed more intensive treatment. Humana told reviewers that the lack of an in-network lower-level care facility for patients to go to was not a reason to approve post-acute care and that usually the situations can be “sorted out,” presumably by the patient with no help from the insurer.

All three companies (UnitedHealth, Humana and CVS/Aetna), which dominate the Medicare Advantage program,  demonstrated a striking lack of motivation to protect and enhance patient care, instead showing a primary motivation to increase profits and margins. 

The subcommittee’s report also noted that UnitedHealth, CVS/Aerna, and Humana are increasingly using AI to make care decisions and cutting humans, especially doctors, out of the process. The researchers found that in 2022, UnitedHealth looked into how using AI and machine learning could aid in predicting which denials of post-acute care requests were most likely to be overturned.  One would hope this effort would be to decrease the number of wrongfully denied prior authorization requests and increase patient access to care.

However, the report includes a quote from a recap of a meeting on the project asking “what we could do in the clinical review process to change the outcome of the appeal,” meaning that UnitedHealth was interested in preventing the overturning of denials, not getting the decision right in the first place. The report also found evidence that naviHealth used artificial intelligence to help determine the coverage decisions for a patient’s post-acute care claim before any human post-acute care providers evaluated a case. The report’s authors found that denials for post-acute care facilities rose rapidly once naviHealth began managing these requests for UnitedHealth’s MA plans. 

These are just some of the findings in the 54-page report on Big Insurance’s use of prior authorization to deny Medicare Advantage patient requests for post-acute care.

The report’s findings demonstrate the abuse of prior authorization by the insurers, the motivation to increase profit and decrease patient care, and the use of AI to increase denials. Further, the findings underscore that prior authorization is a tool used by Big Insurance primarily to maximize profits. The report puts forward recommendations to cut down on abusive denials, which would have some positive impact.

More importantly, I believe the report provides more evidence that it is becoming exceedingly less likely that private and for-profit insurance companies can be regulated and act in a way that promotes patient health over profits.

Agents and brokers for Medicare Advantage plans using deceptive marketing tactics

Posted on by • Posted in Abuse, Center for Medicare and Medicaid Services (CMS), Deceptive Advertising, Health Insurance Benefit Design, Health Insurance Industry, Marketing, Medicare Advantage • Leave a comment

https://mailchi.mp/cfd0577540a3/the-weekly-gist-november-11-2022?e=d1e747d2d8

 In their latest article scrutinizing the MA program, New York Times reporters Reed Abelson and Margot Sanger-Katz highlight MA marketing practices brought to light in a recent report from the Senate Finance Committee. Complaints to the Centers for Medicare and Medicaid Services (CMS) about MA marketing more than doubled from 2020 to 2021, as agents and brokers took advantage of oversight rules relaxed during the Trump administration. Some of the most egregious alleged abuses include agents switching seniors into new plans without their consent and exploiting individuals with cognitive impairments.

The Gist: Media interest is finally catching up to the building legislative and regulatory pressure on Medicare Advantage. While earlier reporting has highlighted how plans can inflate payments from Medicare, this new story shows how the process of selecting a plan can be fraught for the seniors enrolled. 

Plan design is confusing even for industry insiders, so it is no surprise that seniors might find themselves ‘choosing’ plans that omit key providers, or even drug coverage they already rely on, particularly after being badgered or misled by agents and brokers.

Many of the regulatory fixes highlighted in the report can be implemented directly by CMS, but insurers, who remember the managed care backlash of the 90s, shouldn’t wait to tighten the reins on questionable marketing practices, lest they risk losing public support for one of their most lucrative business lines.

Telehealth blurs the line between Prescription and Over-the-Counter Drugs

Posted on by • Posted in Abuse, Consumer Driven Health, Consumer Engagement, Consumer Marketing, Consumer Preferences, Consumer Segmentation, Consumerism, Market Trends, Prescription Drugs, Telemedicine • Leave a comment

https://mailchi.mp/e60a8f8b8fee/the-weekly-gist-september-23-2022?e=d1e747d2d8

 A recent STAT News article highlights a concerning new trend in direct-to-consumer pharmaceutical marketing, enabled by access to virtual care. Pitched as a tool for patient empowerment, pharmaceutical companies are now offering consumers immediate treatment for a variety of health conditions at the click of a button that says, “Talk to a doctor now.”

Over 90 percent of eligible patients receive a prescription for the drug they “clicked” on, after connecting with a virtual care provider on a third-party telehealth platform. Not only does this practice give drug companies direct access to prospective patients, but it also delivers lucrative data on patient age, zip code, and medication history that can be used to target marketing efforts.

The Gist: Articles like this remind us why the US is one of only two countries in the world that allows direct-to-consumer marketing of prescription drugs (the other, interestingly, is New Zealand). 

As the number of Americans with a primary care provider continues to decline, this kind of Amazon-style, easy-button drug shopping experience will be increasingly appealing to many consumers. But wherever innovation outpaces regulation, situations in which for-profit companies prioritize profits over providing the best care for patients are sure to occur.

While we support the idea of greater consumer empowerment in healthcare, we worry that this highly fragmented approach to consumer-driven health can result in abuse and patient harm.

Standing Up to a Tidal Wave of Ignorance, Fear and Abuse

Posted on by • Posted in 2020 Election Issues, Abuse, Core Values, Coronavirus, Crisis, Crisis Management, Desperation, Fear, Front Lines, Health Policy, Healthcare Providers, Ignorant, Infection Control, Infectious Virus, Nurses, Pandemic, Physician, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

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Today I stood with some of my fellow nurses and faced a tidal wave of ignorance, fear, and abuse.

I was mocked. I was called more names than I can remember. I was told I was ignorant, unintelligent, and compassionless. I was accused of being a fake nurse, a paid protester, a fraud. I was told I was nothing. I had cigarette smoke blown in my face. I was sexually harassed. A few times, I was surrounded on all sides by multiple people yelling at me.

Desperation and fear bring out the worst in people. I will admit, I cried a bit. How could I not in the face of so much hate?

But I when I did, I was crying for my fellow healthcare workers on the front lines, who are working their asses off fighting this illness, who are being put at worse risk because of the lack of essential protective equipment in this country. I cried for those who have left their families behind to go help where the situation is most dire. I cried for those who have died and will continue to die, after working their hardest to help those who needed them.

I cried for every protester who doesn’t know how they are going to make ends meet, that are afraid for their businesses, their jobs, their homes, and their lives. I cried for every American who has received less than adequate help from the government, who felt like this is the only way for them to get the resources they need, and who have been failed by our president who has not implemented the measures required to help and protect our most vulnerable people.

I cried for every person at this protest that will inevitably get sick, and increase the spread in our state when we had been doing a pretty good job of flattening the curve and delaying the spread of covid-19 in Arizona. I cried for every person who will be infected by those that contracted the disease today.

But more important than the few tears I shed today, was that I stood strong for what is right.

I stood for using science, not feelings, to make important decisions in a pandemic. I stood for the healthcare workers who are going to keep working our hardest to help heal the sick, whether they appreciate it or not. I stood for those who couldn’t. I stood for the lives we have lost, many unnecessarily, to this virus. I stood strong and looked every protester fighting to open Arizona in the eye, so they would have to stare into the face of some of the individuals they are hurting with their ignorance. My hands cramped up from standing in this position so long, but I kept standing until everything died down.

And I will keep standing.