This article was originally published in Politico on Oct. 17, 2024
United Healthcare, the nation’s largest Medicare Advantage insurer, more than doubled the rate at which it denied care following hospital stays for its patients between 2020 and 2022.
Humana’s denial rate for a similar type of care grew 54 percent during the same period.
And at CVS Health, the number of care requests for similar services that the insurer required prior approval increased nearly 58 percent from 2019 to 2022.
These were some of the details laid out in a long-awaited Senate report released Thursday from Democratic staff on the Senate Homeland Security Committee’s investigative subcommittee.
The Senate report is the latest example of increased scrutiny being applied to Medicare Advantage after years of complaints about care denials. And it comes amid bipartisan interest in reforming the private insurance system that now counts more than half of older Americans as members.
The report lands more than a year after the Permanent Subcommittee on Investigations launched a probe into the three largest Medicare Advantage insurers — Humana, UnitedHealthcare and CVS Health’s Aetna — which revealed that the companies deny prior authorization requests for post-acute care at far higher rates than other types of care. Post-acute care, which can be costly, generally refers to a medical service provided after a short hospital stay, including home health care or a stay at a skilled nursing facility.
During its investigation, the committee demanded the companies explain the role algorithms play in denying prior authorization requests, which require doctors to seek approval before providing certain types of care. The companies provided more than 280,000 pages of documents to the committee, according to the report.
“There is a role for the free market to improve the delivery of healthcare to America’s seniors, but there is nothing inevitable about the harms done by the current arrangement,” the report says. “Insurers can and must do better, for the sake of the American healthcare system and the patients the government entrusts to them.”
A spokesperson for CVS said the report “significantly misrepresents CVS Health’s use of prior authorization” and that the companies prior authorization protocols are routinely audited by the Centers for Medicare and Medicaid Services and found to be in compliance.
“Many of the documents cited are outdated, while others are drafts or were used for internal company deliberations and therefore are not reflective of final decisions,” spokesperson Phil Blando said in a statement.
A spokesperson for United Healthcare said the report “mischaracterizes the Medicare Advantage program and our clinical practices, while ignoring CMS criteria demanding greater scrutiny around post-acute care.”
“This is a partisan report laden with errors and misleading claims. In fact, Senator Blumenthal’s team declined to correct those errors and mischaracterizations that Humana identified after reviewing certain heavily redacted excerpts prior to the report’s release,” Humana said in a statement.
Why it matters: The 54-page report puts Medicare Advantage insurers in the hot seat once again as Congress has grown increasingly critical of the companies and of artificial intelligence’s role in health care. It also lands as the federal government has cracked down on overpayments to the privately run alternative to Medicare, which has led insurers to scale back their benefits and pull out of some counties. And a rising number of hospitals are dropping Medicare Advantage plans, citing excessive prior authorization denials and slow payments.
Background: Insurers contend they use prior authorization to ensure care is medically necessary and to lower costs. Nearly all Medicare Advantage enrollees are in plans that use prior authorization for some services, according to KFF, a health care policy think tank.
As the program — nearly 33 million Americans are enrolled in it — becomes more popular, lawmakers have become concerned about barriers to care amid a jump in prior authorization denials. Lawmakers in June reintroduced the Improving Seniors’ Timely Access to Care Act , which mandates insurers more quickly approve requests for routine care. The bill secured bipartisan majority support in the House last week. The bill also has bipartisan support in the Senate, with 54 cosponsors.
The findings: The Democrats’ report found that:
— In 2022, both UnitedHealthcare and CVS denied prior authorization requests for post-acute care at rates that were about three times higher than the companies’ denial rates for all types of prior authorization requests.
— In 2022, Humana denied prior authorization requests for post-acute care at a rate that was more than 16 times higher than its overall denial rate.
— UnitedHealthcare’s prior authorization denial rate for post-acute care jumped from 10.9 percent in 2020 to 22.7 percent in 2022, as the company was working to automate the process.
— CVS’ prior authorization denial rate for post-acute care remained relatively stable from 2019 to 2022. But the number of post-acute care service requests that required prior authorization increased by 57.5 percent.
— Humana’s denial rate for long-term acute care hospitals — the most expensive type of post-acute care — grew by 54 percent between 2020 and 2022.
The committee staff recommends that CMS begins collecting prior authorization information broken down by types of care, conduct targeted audits of insurers and expand regulations on insurers’ use of predictive technologies in prior authorization.
A CMS spokesperson said the agency “appreciates the work of Congress” and is reviewing the report. The agency continues to receive “many inquiries” about the use of prior authorization, and any additional changes to the CMS’ policies would be proposed through rulemaking, the spokesperson said.
“CMS has taken many steps to address the use of prior authorization by MA plans and ensure that people with Medicare Advantage have timely access to care and receive access to the same medically necessary care they would receive in Traditional Medicare,” the spokesperson said.
