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Sun Oct 1, 2023, 08:36 AM Oct 2023

U.S. to rein in technology that limits Medicare Advantage care (WP) [View all]

Last edited Sun Oct 1, 2023, 02:18 PM - Edit history (2)


U.S. to rein in technology that limits Medicare Advantage care
By Susan Jaffe
October 1, 2023 at 7:00 a.m. EDT

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said, and she still needed help using a colostomy bag after her operation.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have NaviHealth, a care management company it bought in 2020, and one of several businesses that use predictive technology to help insurance companies make coverage decisions.

Its proprietary “NH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions and other factors. Based on these comparisons, an algorithm anticipates what kind of care specific patients will need and for how long.

But patients, providers and patient advocates in several states said they have noticed a suspicious coincidence: The tool often predicts a patient’s date of discharge that coincides with the date their insurer cuts off coverage, even if the patient needs further treatment that government-run Medicare would provide.




Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
By Casey Ross and Bob Herman
March 13, 2023

An algorithm, not a doctor, predicted a rapid recovery for Frances Walter, an 85-year-old Wisconsin woman with a shattered left shoulder and an allergy to pain medicine. In 16.6 days, it estimated, she would be ready to leave her nursing home.

On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone. Meanwhile, medical notes in June 2019 showed Walter’s pain was maxing out the scales and that she could not dress herself, go to the bathroom, or even push a walker without help.

It would take more than a year for a federal judge to conclude the insurer’s decision was “at best, speculative” and that Walter was owed thousands of dollars for more than three weeks of treatment. While she fought the denial, she had to spend down her life savings and enroll in Medicaid just to progress to the point of putting on her shoes, her arm still in a sling.

Health insurance companies have rejected medical claims for as long as they’ve been around. But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.

Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.

“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”


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Maybe those that tout the superiority of "part c"... ret5hd Oct 2023 #1
+1. Medicare Advantage companies can ignore this new rule without penalties dalton99a Oct 2023 #4
Amen!!! Traildogbob Oct 2023 #6
I'm taking traditional Medicare in Dec nt XanaDUer2 Oct 2023 #2
You are wise to do so. OMGWTF Oct 2023 #13
Medicare Advantage is part of the Medicare law. former9thward Oct 2023 #19
Yes we must put a stop to this. tiredtoo Oct 2023 #20
In the door,... out the door,... magicarpet Oct 2023 #3
. dalton99a Oct 2023 #5
++++ And as I understand it, much of the Medicare Advantage profit margin comes from outright KPN Oct 2023 #14
You win the post of this thread, gab13by13 Oct 2023 #21
Medicare Part C plans were first created in 1997 MichMan Oct 2023 #22
Just a quibble wryter2000 Oct 2023 #7
I have BCBS of Michigan Medicare Advantage PPO DownriverDem Oct 2023 #8
Yes, it does "help with expenses" and you'll be fine as long as you don't get really ill. Biophilic Oct 2023 #10
The advantages of Medicare Advantage and Medicare will diminish as the demographic ages. jaxexpat Oct 2023 #25
A recent episode of consumer advocate Clark Howard's podcast Pinback Oct 2023 #9
For-profit healthcare is about generating high profits dlk Oct 2023 #11
This message was self-deleted by its author elocs Oct 2023 #12
Advantage plans are an attempt to privatize Medicare. They're succeeding. Lonestarblue Oct 2023 #15
They are also an attempt to make Medicare as a government KPN Oct 2023 #33
it disgusts me seeing DUers recommending MA Skittles Oct 2023 #41
Healthcare management companies have to get their slice of the pie. Of course, they are sending littlemissmartypants Oct 2023 #16
does anyone know of a guide NJCher Oct 2023 #17
The Federal government sends out a book annually MichMan Oct 2023 #24
You can do that from Jan 1 thru March 31st. Here's the link Native Oct 2023 #26
excellent! NJCher Oct 2023 #29
The problem is that once you are in MA Voltaire2 Oct 2023 #46
not surprising NJCher Oct 2023 #50
My neighbor signed up because of the dental cleanings dalton99a Oct 2023 #51
As a practical matter, you may be unable to. Ms. Toad Oct 2023 #56
The new rules go into effect on Jan. 1st. Here's what will change... Native Oct 2023 #18
"Will be expected"? As in "if they want to"? Autumn Oct 2023 #23
No, they have to comply. I'm sure they'll come up with a way to circumvent this though. Native Oct 2023 #27
To me the words "expected to" doesn't mean one has to do anything. Autumn Oct 2023 #28
+1. There are no penalties for violations dalton99a Oct 2023 #30
Yup. There are plenty of medical healthcare experts in the pockets KPN Oct 2023 #34
Change NowISeetheLight Oct 2023 #31
Do People Believe RobinA Oct 2023 #32
Have you had direct experience? Because I have. W_HAMILTON Oct 2023 #38
The disparity is enormous and well documented dalton99a Oct 2023 #42
Direct Experience? RobinA Oct 2023 #53
I have yet to speak with anyone in the profession... W_HAMILTON Oct 2023 #54
You should help your mother go back and review the physical therapy. Ms. Toad Oct 2023 #58
You are wrong. Ms. Toad Oct 2023 #57
We'll Have To RobinA Oct 2023 #61
Neither I, not my parents, not my spouse has had a single denial Ms. Toad Oct 2023 #62
As I Said RobinA Oct 2023 #64
You can verify the price for policies in Pennsylvania Ms. Toad Oct 2023 #65
This message was self-deleted by its author ymetca Oct 2023 #35
In other news, rich executives get richer agreeing to kick granny off the cliff. lostnfound Oct 2023 #36
+1. Dental cleanings and gym memberships are shiny objects they use to lure and entrap people dalton99a Oct 2023 #39
yeah, it's just a cooincidence Skittles Oct 2023 #40
I'm going to be stuck between a rock and a hard place... Lars39 Oct 2023 #43
Coverage begins in January per the 2022 Lymphedema Treatment Act dalton99a Oct 2023 #44
Do you have a link? Lars39 Oct 2023 #47
Here are some: dalton99a Oct 2023 #48
Thank you! Lars39 Oct 2023 #49
Great! Ms. Toad Oct 2023 #60
That stinks. Ms. Toad Oct 2023 #59
MA is a corrupt scam. Voltaire2 Oct 2023 #45
I'll go further: MA should be shot with a silver bulllet justaprogressive Oct 2023 #52
I have United HealthCare, but it is impossible for them to cut me off. Ms. Toad Oct 2023 #55
This is going to continue to happen unless the US switches to universal healthcare. area51 Oct 2023 #63
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