Headline: Medicare Advantage Insurer Cuts Coverage Based on Algorithm, Raising Concerns
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In a disconcerting development, UnitedHealthcare, the nation’s largest health insurance company, has been using a predictive technology tool to make coverage decisions for its Medicare Advantage plan. The tool, known as “NH Predict,” analyzes millions of medical records to determine the kind of care that specific patients will need and for how long. However, patients, providers, and advocates have noticed a suspicious trend – the algorithm often predicts a patient’s discharge date that coincides with the date their insurance coverage is cut off.
One such patient, Judith Sullivan from Connecticut, was recovering from major surgery at a nursing home when she received a notification from her Medicare Advantage plan that it would no longer cover her care because she was well enough to go home. This decision was made without any in-person evaluation of her condition or needs. Sullivan, 76, was still unable to walk more than a few feet and required assistance with basic tasks.
UnitedHealthcare’s acquisition of NaviHealth, a care management company, has enabled the insurer to use predictive technology to make coverage decisions. The algorithm assesses factors such as age, preexisting health conditions, and other characteristics to determine the appropriate level and length of care for patients. However, critics argue that algorithms alone cannot fully consider a patient’s individual needs and that human intervention is necessary.
Coincidentally, the algorithm’s predicted discharge dates often align with the dates when insurers cut off coverage, even if patients require further treatment that would be covered by government-run Medicare. Nursing home care, in particular, has been frequently denied by Medicare Advantage plans, despite being covered by original Medicare.
The Department of Health and Human Services’ inspector general has raised concerns that private insurance companies have a potential incentive to deny access to services and payment in an attempt to increase profits. Nursing home care, which is a commonly denied service, can lead to significant financial burdens for patients. For example, Sullivan’s additional 18 days of treatment after her coverage was cut off resulted in a bill of $10,406.36.
Starting next year, the Centers for Medicare and Medicaid Services will impose restrictions on the use of predictive technology tools by Medicare Advantage plans when making coverage decisions. The new rules aim to ensure that coverage decisions are based on individual circumstances and require a review by a physician or other appropriate healthcare professional.
While these rule changes are promising, concerns remain about enforcement and penalties for violations. It is crucial to hold insurance companies accountable for ensuring that patients receive the necessary care and not solely rely on algorithmic predictions.
Overall, the use of predictive technology tools by insurers to make coverage decisions must be approached cautiously. While these tools can be useful in improving care coordination and reducing costs, they should never replace the expertise and individualized assessments of healthcare providers. Patients’ needs should always take precedence over algorithms.