A recent PSI inquiry into MA post-acute treatment denials has revealed seniors are being refused care at especially vulnerable times.
Recent findings from the Senate Homeland Security Permanent Subcommittee on Investigations (PSI) have revealed a disturbing trend in the Medicare Advantage (MA) system where seniors are increasingly being denied post-acute care services. The investigation, which focused on the three-year period from 2020 to 2023, shows how the three largest MA insurers—UnitedHealthcare, Humana, and Aetna—have significantly increased coverage denial rates for services such as nursing homes, inpatient rehabilitation facilities, and long-term acute care hospitals. These denials, driven by unregulated algorithms and technologies, are leaving vulnerable seniors without the follow up care they need after being discharged from hospitals.
In May 2023, the PSI initiated an inquiry into the barriers facing seniors enrolled in Medicare Advantage plans when trying to access post-acute care. The subcommittee gathered documents from UnitedHealthcare, Humana, and Aetna, which together cover nearly 60% of MA enrollees in the U.S. The findings revealed that these insurers are using prior authorization processes to restrict access to post-acute care services, prioritizing their profits over patient well-being. By focusing on post-acute care, insurers target a critical phase of recovery for seniors, making it difficult for them to receive the necessary extended care after hospitalization during a time where it is especially difficult to fight for coverage.
The Federation of American Hospitals (FAH) have echoed the committee’s concerns, stating that the report provides evidence for what they have already been warning consumers about for years. FAH President and CEO Chip Kahn expressed frustration, stating that seniors are being abandoned by MA plans that delay and deny vital care. The report serves as a call to action for legislators and regulators to hold these insurers accountable for their practices and to ensure that patients receive the care they need without unnecessary obstacles.
The problem of increased denials extends beyond just hospital settings, too, as home health care providers have encountered similar challenges. According to the report, in 2022, UnitedHealthcare and Aetna denied prior authorization requests for post-acute care at rates nearly three times higher than their overall denial rates for all other medical services. Humana’s numbers are even more shocking, with the insurer denying post-acute care at a rate more than 16 times higher than its overall denial rate. These findings suggest a deliberate strategy to restrict post-acute care, using prior authorization as a cost-saving mechanism above all else.
As the report points out, automation has played a significant role in this troubling trend. For example, UnitedHealthcare’s denial rate for post-acute care nearly doubled from 10.9% in 2020 to 22.7% in 2022, due in part to an automation project designed to reduce costs. Humana also experienced a substantial rise in denials for long-term acute care hospitals, with a 54% increase between 2020 and 2022. CVS Health, which owns Aetna, implemented a post-acute care analytics system in April 2021, relying on artificial intelligence (AI) to cut costs for skilled nursing facilities. Initially expected to save $4 million annually, the initiative quickly grew, with CVS projecting savings of more than $77 million over three years. These savings were tied directly to a hike in prior authorization requirements, showing a direct link between AI-driven denials and cost reductions.
These practices raise significant ethical and regulatory concerns, with insurers getting away with minimizing expenditures while putting patients’ lives at stake. Post-acute care denials can lead to slower recovery times, increased hospital readmissions, and diminished quality of life for seniors relying on these services.
LeadingAge, an organization representing over 5,400 nonprofit aging service providers, has voiced its own concerns about the growing rate of denials in post-acute care under Medicare Advantage plans. The organization’s president, Katie Smith Sloan, affirmed that the data supports the experiences of their members, who have consistently reported difficulties in obtaining necessary care approvals for seniors. LeadingAge has called for increased oversight and regulation to ensure that prior authorization processes do not prevent patients from receiving critical services.
In light of these findings, the PSI has recommended that the Centers for Medicare & Medicaid Services (CMS) take action to address the issue. Among the recommendations are the collection of more detailed data on prior authorization requests, including breakdowns by service category, and conducting audits to assess whether the increasing use of predictive technologies by insurers is leading to higher rates of adverse outcomes for patients. The subcommittee also called for CMS to expand regulations that ensure human oversight in authorization decisions, preventing algorithms from having unchecked power over patient care.
As the investigation continues, it is clear that the current practices within Medicare Advantage plans are failing to protect seniors, and these cost-cutting measures raise serious concerns about the future of senior healthcare in the U.S. Without regulatory intervention, the predatory practices are likely to continue, leaving more patients without the support they need during times when these services are most critical.
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