Judith Sullivan, a patient recovering from surgery at a nursing home, was notified by her Medicare Advantage plan that it would no longer cover her care because she was well enough to go home. Sullivan, who still required assistance to move and use a colostomy bag, was surprised by the decision and questioned how it was made without anyone physically evaluating her condition. UnitedHealthcare, the largest health insurance company in the US and provider of Sullivan’s Medicare Advantage plan, uses NaviHealth, a care management company, to make coverage decisions using predictive technology. Many patients and healthcare providers have noticed a pattern in which patients are discharged on the same date that their coverage is cut off, even if they still require further treatment. Medicare Advantage plans, which are operated by private insurance companies and offer enhanced benefits, have been denying coverage for nursing home care despite it being covered by original Medicare.
Patients, providers, and patient advocates have expressed concern about the use of predictive technology in coverage decisions, emphasizing the need for human intervention to consider a patient’s individual needs. To address these concerns, the Centers for Medicare and Medicaid Services will restrict the use of these tools next year, requiring Medicare Advantage plans to consider an individual’s circumstances when making medical necessity determinations. The new rules also require coverage denials to be reviewed by a physician or other healthcare professional with expertise in the relevant field. However, questions remain about how these rules will be enforced and whether specific penalties will be imposed for violations.