If you were looking for someone deserving to be cast as Ebenezer Scrooge this holiday season, Medicare Advantage insurers may have just locked up the audition (for this year and maybe future years too).
Already under increasing scrutiny at 2023’s end thanks to a series of freshly enacted and proposed regulations, news that broke during McKnight’s holiday break demonstrates just why so many lawmakers seem interested in putting these giant providers back under their collective thumb.
On Thursday, STAT News published yet another damning story about practices UnitedHealth Group allegedly has used to shorten skilled nursing stays (or in some cases, deny them all together). Such practices not only make the nation’s largest MA plan provider look like a big ol’ miserly meanie, they add to a list of thorny questions about whether plans have violated patient rights or run afoul of existing regulations.
UnitedHealth and Humana each became targets of class-action lawsuits as 2023 drew to a close, with patients arguing that the use of artificial-intelligence-fed algorithms led to care that ended early and despite doctors’ orders to the contrary.
As if that weren’t bad enough, STAT now cites internal documents that show United used “secret rules to restrict access to rehabilitation care requested by specific groups of seriously ill patients, including those who lived in nursing homes or suffered from cognitive impairment.”
That didn’t require any special technology. Based on its review, STAT reported that the rules guided clinicians who review rehab referrals and led to quick denials. But in November, according to an employee cited by STAT, the practice was abruptly ended and those reviewers told to use more “discretion.”
The change seems anything but discreet. This year, the Centers for Medicare & Medicaid Services is set to begin auditing MA denials, providing key new information that federal lawmakers have clamored for over the last two years. Skilled nursing providers, too, have asked for more information on denials, observing that patients are sometimes given vague explanations that deny them access to care traditional Medicare beneficiaries receive.
MA growth amid the flak
The news is inauspicious, coming as it does on the heels of MA’s biggest year yet. In 2023, more than 50% of Medicare beneficiaries opted into MA plans for the first time, with aggressive marketing and apparent out-of-pocket costs expected to have taken that figure higher in the enrollment period that ended Dec. 7.
But as I’ve written in this space before, it does seem that we could finally be at a turning point.
Plans last fall were required to cut out some types of advertising tactics that consumer groups had said intentionally confused or misled patients. We’ll see if that makes any dent in the actual enrollment figures (though a federal campaign and a formal regulatory complaint also promise to keep the heat on that issue).
And skilled nursing advocates have praised a proposed rule (comments due Friday) that would give patients a clear path to appeal MA denials, a process that until now has been considered muddy at best.
Yes, it appears our Scrooge seems to be in the midst of its Dickensian rite of passage of sorts. Instead of ghosts of past, present and future, however, this star turn involves the spirit of the law, the heart of the patient and the rule of the regulator.
No doubt, some plan leaders are still in a Bah Humbug! mood as they move into 2024. Let’s see if they come out of this experience feeling any more generous toward their customers.
Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.
Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.
