Feds rein in use of predictive software that limits care for Medicare Advantage patients

Judith Sullivan was recovering from major surgery in a Connecticut nursing home in March when her Medicare Advantage plan informed her that it would no longer pay for her care because she was well enough to go home.

She said she couldn’t walk more than a few feet without assistance, let alone manage the stairs to her front door. Following major surgery, she still required assistance with using a colostomy bag.

“How could they make a decision like that without ever coming and seeing me?” said the 76-year-old Sullivan. “I couldn’t walk without one physical therapist in front of me and another behind me.” “Would they all accompany me home?”

UnitedHealthcare, the nation’s largest health-care provider and provider of Sullivan’s Medicare Advantage plan, does not have a crystal ball. It does, however, have naviHealth, a care management company that will be purchased by UHC’s sister company, Optum, in 2020. Both are affiliated with the UnitedHealth Group. NaviHealth analyzes data to assist UHC and other insurance providers in making coverage decisions.

Its proprietary “nH Predict” tool searches millions of medical records for patients with similar diagnoses and characteristics, such as age, preexisting health conditions, and other factors. An algorithm predicts what type of care a specific patient will require and for how long based on these comparisons.

However, patients, providers, and patient advocates in several states have reported a suspicious coincidence: the tool frequently predicts a patient’s discharge date, which coincides with the date their insurer discontinues coverage, even if the patient requires additional treatment that government-run Medicare would provide.

“When an algorithm does not fully consider a patient’s needs, there’s a glaring mismatch,” said Rajeev Kumar, a physician and the president-elect of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “That’s where human intervention comes in.”

When the Centers for Medicare & Medicaid Services begins limiting how Medicare Advantage plans use predictive technology tools to make some coverage decisions next year, the federal government will attempt to level the playing field.

Private insurance companies operate Medicare Advantage plans, which are an alternative to the government-run original Medicare program. Approximately half of those eligible for full Medicare benefits are enrolled in private plans, drawn by lower costs and enhanced benefits such as dental care, hearing aids, and a slew of nonmedical extras such as transportation and home-delivered meals.

The federal government pays insurers a monthly payment for each enrollee, regardless of how much care they require. According to the inspector general of the Department of Health and Human Services, this arrangement increases “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits.” Nursing home care has been among the most frequently denied services by private plans, despite the fact that original Medicare would most likely cover it, according to investigators.

After UHC terminated her nursing home coverage, Sullivan’s medical team agreed with her that she wasn’t ready to go home and extended her stay for an additional 18 days. Her total bill was $10,406.36.

When UHC stopped paying for Sullivan’s nursing home care, “she also had a surgical wound that required daily dressing changes,” said Debra Samorajczyk, a registered nurse and administrator at the Bishop Wicke Health and Rehabilitation Center, where she was treated.

Neither Sullivan’s coverage denial notice nor her nH Predict report mentioned wound care or her inability to climb stairs. According to Samorajczyk, original Medicare would have most likely covered her continued care.

Sullivan appealed twice but lost both times. Her next appeal was heard by an administrative law judge, who conducts a courtroom-style hearing via phone or video link in which all parties can testify. Despite the fact that UHC did not send a representative, the judge ruled in favor of the company. Sullivan is debating whether to appeal to the Medicare Appeals Council, the final step before the case can be heard in federal court.

Sullivan’s story is not unique. In February, Ken Drost’s Medicare Advantage plan, Security Health Plan of Wisconsin, proposed terminating his coverage at a Wisconsin nursing home after 16 days, the same number of days predicted by naviHealth. However, Drost, 87, who was recovering from hip surgery, required assistance getting out of bed and walking. He stayed at the nursing home for an extra week, which cost $2,624.

After losing his first two appeals, his third appeal was about to begin when his insurer agreed to pay his bill, according to his lawyer, Christine Huberty of the Greater Wisconsin Agency on Aging Resources Elder Law & Advocacy Center in Madison.

“Advantage plans, such as Humana, Aetna, Security Health Plan, and UnitedHealthcare, routinely cut patients’ stays in nursing homes short,” she said. “In all cases, we see their treating medical providers disagree with the denials.”

UnitedHealthcare and naviHealth declined interview requests and did not respond to detailed questions about why Sullivan’s nursing home coverage was terminated despite her medical team’s objections.

According to Aaron Albright, a naviHealth spokesperson, the nH Predict algorithm is not used to make coverage decisions, but rather to “assist the member and facility in developing personalized post-acute care discharge planning.””Length-of-stay predictions are only estimates.”

naviHealth’s website, on the other hand, brags about saving plans money by limiting care. According to the business, its “predictive technology and decision support platform” will guarantee that “patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions.”

Beginning in January, new federal rules for Medicare Advantage plans will limit their use of algorithms in coverage decisions. The requirements state that insurance companies using such tools must “ensure that they are making medical necessity determinations based on the circumstances of the specific individual,” rather than “using an algorithm or software that does not account for an individual’s circumstances.”

The CMS-mandated notices that nursing home residents now receive when their coverage is terminated can be strangely similar while lacking details about a specific resident. Sullivan’s UHC notice is nearly identical to the one Drost received from his Wisconsin plan. Both claim, for example, that the plan’s medical director reviewed their cases, but neither name nor medical specialty is provided. Both make no mention of their medical conditions, which make living at home difficult, if not impossible.

The tools must still adhere to Medicare coverage criteria and cannot deny benefits that are covered by original Medicare. If insurers believe the criteria are too broad, they can base algorithms on their own criteria, as long as the medical evidence supporting the algorithms is disclosed.

In addition, before denying coverage deemed not medically necessary, a coverage denial “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue.”

Patients and providers have no say in whether the doctor reviewing a case has experience with the client’s diagnosis, according to Jennifer Kochiss, a social worker at Bishop Wicke who assists residents with insurance appeals. The new requirement will fill “a big hole,” she claims.

In comments submitted to CMS, the leading MA plans express their opposition to the changes. UHC’s CEO for Medicare and retirement, Tim Noel, stated that the ability of MA plans to manage beneficiaries’ care is required “to ensure access to high-quality safe care and maintain high member satisfaction while appropriately managing costs.”

Eliminating “utilization management tools would markedly deviate from Congress’ intent in creating Medicare managed care because they substantially limit MA plans’ ability to actually manage care,” he wrote.

UHC spokesperson Heather Soule said in a statement that the company’s current practices are “consistent” with the new rules. “Medical directors or other appropriate clinical personnel, not technology tools, make all final adverse medical necessity determinations” before coverage is denied or terminated. These medical professionals, however, work for UHC and do not typically examine patients. Other insurance companies do the same thing.

Because the rules do not specify specific penalties for violations, David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS will enforce them.

Meena Seshamani, CMS’s deputy administrator and director of the Medicare program, stated that the agency will conduct audits to ensure compliance with the new requirements and “will consider issuing an enforcement action, such as a civil money penalty or enrollment suspension, for the non-compliance.”

Sullivan stayed at Bishop Wicke after UHC stopped paying, but another resident left when her MA plan stopped paying. The woman fell after two days at home and was taken to the hospital by ambulance, according to Sullivan. “She was back in the nursing home again because they put her out before she was ready.”