UnitedHealth, CVS and Humana Increasingly Deploy AI and Deny Post-Acute Care Claims, Senate Report Finds

Fierce Healthcare / By Noah Tong
 
The country’s three largest Medicare Advantage (MA) insurers obstruct seniors’ ability to receive post-acute care, a scathing report from the U.S. Senate Permanent Subcommittee on Investigations shows.
 
It outlines attempts from UnitedHealthcare, CVS and Humana—which collectively cover nearly 60% of all MA enrollees—to use technology to reject prior authorization claims, all while reaping profit.
 
Between 2019 and 2022, the three insurers denied claims for post-acute care at “far higher” rates than for other types of care, and, in 2022, Humana denials in post-acute care were 16 times higher than the companies’ overall denial rates, the report (PDF) says. 
UnitedHealthcare and CVS denials were three times higher in the same year.
 
“Insurance companies say that prior authorization is meant to prevent unnecessary medical services,” said Sen. Richard Blumenthal, D-Connecticut, in a statement. “But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions. In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors—simply to make more money. Our subcommittee even found evidence of insurers expanding this practice in recent years.”
 
The committee began the investigation in May 2023 and analyzed more than 280,000 pages of internal documents. The report was produced by Blumenthal’s staff. It reveals the insurers adopted new automated processes to speed up claims decisions, and, simultaneously, denials often increased.
 
The subcommittee is calling on the Centers for Medicare & Medicaid Services (CMS) to collect prior authorization data by service category and conduct audits when denial rates spike in certain areas. They also want more regulation around insurers’ internal prior authorization committees, because even if AI is only used to approve requests, medical professionals may be facing pressure to go along with AI recommendations in the name of efficiency and cost-cutting.
 
Post-acute care data business naviHealth conducts prior authorization for major insurers, including Blue Cross Blue Shield plans, Stat previously reported. In April 2022, naviHealth told customer service representatives to not help providers with prior authorization questions.
 
“IMPORTANT: Do NOT guide providers or give providers answers to the questions,” naviHealth mandated.
 
By December 2022, UnitedHealthcare had a working group to determine how machine learning could predict which post-acute care cases were most likely to be appealed and overturned. The company’s post-acute care denial rate had already increased from 10.9% in 2020 to 22.7% in 2022.
 
UnitedHealth bought naviHealth in 2020. Since then, naviHealth has rebranded to Optum Home & Community Care, laid off scores of workers and its CEO Harrison Frist resigned, Fierce Healthcare reported. The company is also facing a class-action lawsuit over naviHealth’s denial practices…

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