Medicare Advantage Plans Often Deny Essential Care

Two recent reports by U.S. investigators highlight a troubling trend among Medicare Advantage plans. These plans frequently deny patients’ requests for short-term nursing home or inpatient rehabilitation services.

The reports revealed that major insurers involved in Medicare Advantage plans, specifically UnitedHealth Group, Humana, and CVS Health, have denied approximately 13 percent of patient requests for skilled nursing facility care. This is a significant concern as these facilities are crucial for recovery following surgery or serious illnesses.

Medicare Advantage plans serve around 35 million older Americans under the federal Medicare program. The plans face criticism for delays and denials of medically necessary care. Federal investigators have previously raised these issues, expressing concern about the tactics used by these plans.

These insurance companies require prior authorization before covering treatments. Since plans receive a fixed payment for patient care, they have financial incentives to minimize spending on expensive specialized inpatient care. Instead, they often direct patients to outpatient facilities or send them home prematurely, according to the analysis.

The inspector general’s office at the Department of Health and Human Services conducted the recent reports. Their focus was on the largest companies providing Medicare Advantage plans. The reports highlighted that these companies deny a significant number of requests for specialized care, raising concerns about the supervision of contractors making these decisions.

The dominance of a few large insurance companies in Medicare Advantage and the use of contractors to process prior authorization requests means that the policies and performance of just a few companies can impact care for millions of people, said Rosemary Bartholomew, the government team’s leader.