Medicare Advantage insurers prioritize profits over patients, Senate reports

Editor's Note

A Senate report reveals that Medicare Advantage insurers are increasingly prioritizing profits over patient care by ramping up the use of prior authorization to deny necessary services, particularly post-acute care, for older adults, Becker’s Hospital Review reported October 17.

In May 2023, the Senate Permanent Subcommittee on Investigations began examining UnitedHealthcare, Humana, and CVS Health, the three largest Medicare Advantage insurers, focusing on their prior authorization practices and the technologies used for approval and denial decisions from 2019 to 2022, Becker’s reports In 2022, Medicare Advantage insurers processed more than 46 million prior authorization requests and either fully or partially denied about 7.4% of them. Less than 10% of these denials were appealed, suggesting a gap in the appeal process. Additionally, investigating prior authorization practices was difficult due to the lack of transparency and public reporting requirements. inappropriate practices, such as AI fixing lengths of stay, were often undocumented.

Other key takeaways include:

• From 2019 to 2022, UnitedHealthcare, Humana, and CVS Health had significantly higher denial rates for post-acute care services compared to other types of care.
• UnitedHealthcare's denial rate for post-acute care increased from 10.9% in 2020 to 22.7% in 2022, attributed partly to automation efforts using the naviHealth platform, which was later rebranded as Home & Community Care.
• Although CVS Health's denial rate remained steady, the number of prior authorization requests for post-acute care rose by 57.5% from 2019 to 2022.
• Humana saw a 54% increase in denials for long-term acute care between 2020 and 2022.

Other information and context provided by the full Becker’s report includes disputes from all three companies, subcommittee recommendations on the use of AI, additional details on prior authorization, and more.