{"id":1820,"date":"2023-10-05T09:53:15","date_gmt":"2023-10-05T09:53:15","guid":{"rendered":"https:\/\/healthynewsusa.com\/?p=1820"},"modified":"2023-10-05T09:53:18","modified_gmt":"2023-10-05T09:53:18","slug":"feds-rein-in-use-of-predictive-software-that-limits-care-for-medicare-advantage-patients","status":"publish","type":"post","link":"https:\/\/healthynewsusa.com\/?p=1820","title":{"rendered":"Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients"},"content":{"rendered":"<div>\n<p>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.<\/p>\n<p>At the time, she could not walk more than a few feet, even with assistance \u2014 let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.<\/p>\n<p>\u201cHow could they make a decision like that without ever coming and seeing me?\u201d said Sullivan, 76. \u201cI still couldn\u2019t walk without one physical therapist behind me and another next to me. Were they all coming home with me?\u201d<\/p>\n<p>UnitedHealthcare \u2014 the nation\u2019s largest health insurance company, which provides Sullivan\u2019s Medicare Advantage plan \u2014 doesn\u2019t have a crystal ball. It does have naviHealth, a care management company it bought in 2020, and one of several businesses that use computers to help insurance companies make coverage decisions.<\/p>\n<p>Its proprietary \u201cnH Predict\u201d 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 a specific patient will need and for how long.<\/p>\n<p>But patients, providers, and patient advocates in several states said they have noticed a suspicious coincidence: The tool often predicts a patient\u2019s date of discharge, which coincides with the date their insurer cuts off coverage, even if the patient needs further treatment that government-run Medicare would provide.<\/p>\n<figure class=\"wp-block-embed is-type-rich is-provider-documentcloud wp-block-embed-documentcloud\">\n<p>\n<iframe loading=\"lazy\" title=\"Sullivan report_091323_Redacted (Hosted by DocumentCloud)\" src=\"https:\/\/embed.documentcloud.org\/documents\/23973593-sullivan-report_091323_redacted\/?responsive=1&amp;title=1&amp;embed=1\" width=\"570\" height=\"750\" style=\"border: 1px solid #aaa; width: 100%; height: 800px; height: calc(100vh - 100px); max-width: 570px; max-height: 750px;\" sandbox=\"allow-scripts allow-same-origin allow-popups allow-forms allow-popups-to-escape-sandbox\"><\/iframe>\n<\/p>\n<\/figure>\n<p>\u201cWhen an algorithm does not fully consider a patient\u2019s needs, there\u2019s a glaring mismatch,\u201d 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. \u201cThat\u2019s where human intervention comes in.\u201d<\/p>\n<p>The federal government will try to even the playing field next year, when the Centers for Medicare &amp; Medicaid Services begins restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.<\/p>\n<p>Medicare Advantage plans, an alternative to the government-run, original Medicare program, are operated by private insurance companies. About half the people eligible for full Medicare benefits are enrolled in the private plans, attracted by their lower costs and <a href=\"https:\/\/kffhealthnews.org\/news\/medicare-advantage-plans-cleared-to-go-beyond-medical-coverage-even-groceries\/\">enhanced benefits<\/a> like dental care, hearing aids, and a host of nonmedical extras like transportation and home-delivered meals.<\/p>\n<p>Insurers receive a monthly payment from the federal government for each enrollee, regardless of how much care they need. According to the Department of Health and Human Services\u2019 inspector general, this arrangement raises \u201cthe potential incentive for insurers to deny access to services and payment in an attempt to increase profits.\u201d Nursing home care has been among the <a href=\"https:\/\/oig.hhs.gov\/oei\/reports\/OEI-09-18-00260.pdf\">most frequently denied<\/a> services by the private plans \u2014 something original Medicare likely would cover, investigators found.<\/p>\n<p>After UHC cut off her nursing home coverage, Sullivan\u2019s medical team agreed with her that she wasn\u2019t ready to go home and provided an additional 18 days of treatment. Her bill came to $10,406.36.<\/p>\n<div class=\"wp-block block--newsletter  \" data-type=\"kaiser-health-news\/newsletter\" data-align=\"center\" style=\"\">\n<h4 class=\"newsletter__title\">\n\t\t<a href=\"https:\/\/kffhealthnews.org\/email\/\"><br \/>\n\t\t\tEmail Sign-Up\t\t<\/a><br \/>\n\t<\/h4>\n<p class=\"newsletter__description\">\n\t\tSubscribe to KFF Health News&#8217; free Morning Briefing.\t<\/p>\n<\/div>\n<p>Beyond her mobility problems, \u201cshe also had a surgical wound that needed daily dressing changes\u201d when UHC stopped paying for her nursing home care, said Debra Samorajczyk, a registered nurse and the administrator at the Bishop Wicke Health and Rehabilitation Center, the facility that treated Sullivan.<\/p>\n<p>Sullivan\u2019s coverage denial notice and nH Predict report did not mention wound care or her inability to climb stairs. Original Medicare would have most likely covered her continued care, said Samorajczyk.<\/p>\n<p>Sullivan appealed twice but lost. Her next appeal was heard by an administrative law judge, who holds a courtroom-style hearing usually by phone or video link, in which all sides can provide testimony. UHC declined to send a representative, but the judge nonetheless sided with the company. Sullivan is considering whether to appeal to the next level, the Medicare Appeals Council, and <a href=\"https:\/\/www.hhs.gov\/sites\/default\/files\/omha\/files\/medicare-appeals-backlog.pdf\">the last step<\/a> before the case can be heard in federal court.<\/p>\n<p>Sullivan\u2019s experience is not unique. In February, Ken Drost\u2019s Medicare Advantage plan, provided by Security Health Plan of Wisconsin, wanted to cut his coverage at a Wisconsin nursing home after 16 days, the same number of days naviHealth predicted was necessary. But Drost, 87, who was recovering from hip surgery, needed help getting out of bed and walking. He stayed at the nursing home for an additional week, at a cost of $2,624.<\/p>\n<p>After he appealed twice and lost, his hearing on his third appeal was about to begin when his insurer agreed to pay his bill, said his lawyer, Christine Huberty, supervising attorney at the Greater Wisconsin Agency on Aging Resources Elder Law &amp; Advocacy Center in Madison.<\/p>\n<p>\u201cAdvantage plans routinely cut patients\u2019 stays short in nursing homes,\u201d she said, including Humana, Aetna, Security Health Plan, and UnitedHealthcare. \u201cIn all cases, we see their treating medical providers disagree with the denials.\u201d<\/p>\n<p>UnitedHealthcare and naviHealth declined requests for interviews and did not answer detailed questions about why Sullivan\u2019s nursing home coverage was cut short over the objections of her medical team.<\/p>\n<p>Aaron Albright, a naviHealth spokesperson, said in a statement that the nH Predict algorithm is not used to make coverage decisions and instead is intended \u201cto help the member and facility develop personalized post-acute care discharge planning.\u201d Length-of-stay predictions \u201care estimates only.\u201d<\/p>\n<p>However, naviHealth\u2019s website boasts about saving plans money by restricting care. The company\u2019s \u201cpredictive technology and decision support platform\u201d ensures that \u201cpatients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions.\u201d<\/p>\n<p><a href=\"https:\/\/www.federalregister.gov\/documents\/2023\/04\/12\/2023-07115\/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program\">New federal rules<\/a> for Medicare Advantage plans beginning in January will rein in their use of algorithms in coverage decisions. Insurance companies using such tools will be expected to \u201censure that they are making medical necessity determinations based on the circumstances of the specific individual,\u201d the requirements say, \u201cas opposed to using an algorithm or software that doesn\u2019t account for an individual\u2019s circumstances.\u201d<\/p>\n<p>The CMS-required notices nursing home residents receive now when a plan cuts short their coverage can be oddly similar while lacking details about a particular resident. Sullivan\u2019s notice from UHC contains some identical text to the one Drost received from his Wisconsin plan. Both say, for example, that the plan\u2019s medical director reviewed their cases, without providing the director\u2019s name or medical specialty. Both omit any mention of their health conditions that make managing at home difficult, if not impossible.<\/p>\n<p>The tools must still follow Medicare coverage criteria and cannot deny benefits that original Medicare covers. If insurers believe the criteria are too vague, plans can base algorithms on their own criteria, as long as they disclose the medical evidence supporting the algorithms.<\/p>\n<p>And before denying coverage considered not medically necessary, another change requires that a coverage denial \u201cmust 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.\u201d<\/p>\n<p>Jennifer Kochiss, a social worker at Bishop Wicke who helps residents file insurance appeals, said patients and providers have no say in whether the doctor reviewing a case has experience with the client\u2019s diagnosis. The new requirement will close \u201ca big hole,\u201d she said.<\/p>\n<p>The leading MA plans oppose the changes in comments submitted to CMS. Tim Noel, UHC\u2019s CEO for Medicare and retirement, said MA plans\u2019 ability to manage beneficiaries\u2019 care is necessary \u201cto ensure access to high-quality safe care and maintain high member satisfaction while appropriately managing costs.\u201d<\/p>\n<p>Restricting \u201cutilization management tools would markedly deviate from Congress\u2019 intent in creating Medicare managed care because they substantially limit MA plans\u2019 ability to actually manage care,\u201d he said.<\/p>\n<p>In a statement, UHC spokesperson Heather Soule said the company\u2019s current practices are \u201cconsistent\u201d with the new rules. \u201cMedical directors or other appropriate clinical personnel, not technology tools, make all final adverse medical necessity determinations\u201d before coverage is denied or cut short. However, these medical professionals work for UHC and usually do not examine patients. Other insurance companies follow the same practice.<\/p>\n<p>David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS will enforce the rules since it doesn\u2019t mention specific penalties for violations.<\/p>\n<p>CMS\u2019 deputy administrator and director of the Medicare program, Meena Seshamani, said that the agency will conduct audits to verify compliance with the new requirements, and \u201cwill consider issuing an enforcement action, such as a civil money penalty or an enrollment suspension, for the non-compliance.\u201d<\/p>\n<p>Although Sullivan stayed at Bishop Wicke after UHC stopped paying, she said another resident went home when her MA plan wouldn\u2019t pay anymore. After two days at home, the woman fell, and an ambulance took her to the hospital, Sullivan said. \u201cShe was back in the nursing home again because they put her out before she was ready.\u201d<\/p>\n<aside class=\"meta-authors meta\">\n<p>\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"author-name\">Susan Jaffe: <\/span><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/kffhealthnews.org\/news\/article\/biden-administration-software-algorithms-medicare-advantage\/mailto:Jaffe.KHN@gmail.com\">Jaffe.KHN@gmail.com<\/a>,\t\t\t\t\t\t\t\t\t\t\t<a href=\"http:\/\/twitter.com\/susanjaffe\" target=\"_blank\" rel=\"noopener\"><br \/>\n\t\t\t\t\t\t\t@susanjaffe<\/a>\n\t\t\t\t\t\t\t\t\t<\/p>\n<\/aside>\n<section class=\"block--category-tag-list \">\n<div class=\"category-tag-list__content-wrapper\">\n<h3 class=\"block--category-tag-list__title\">\n\t\t\t\tRelated Topics\t\t\t<\/h3>\n<p>\t\t\t\t<a class=\"category-tag-list__contact-link\" href=\"https:\/\/kffhealthnews.org\/contact-us\/\"><br \/>\n\t\t\tContact Us\t\t<\/a><br \/>\n\t\t<a class=\"category-tag-list__tip-link\" href=\"https:\/\/kffhealthnews.org\/tips\/\"><br \/>\n\t\t\tSubmit a Story Tip\t\t<\/a>\n\t<\/div>\n<\/section><\/div>\n<p><script async src=\"\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":1821,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[],"class_list":["post-1820","post","type-post","status-publish","format-standard","has-post-thumbnail","category-aging"],"_links":{"self":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts\/1820","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1820"}],"version-history":[{"count":1,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts\/1820\/revisions"}],"predecessor-version":[{"id":1822,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts\/1820\/revisions\/1822"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/media\/1821"}],"wp:attachment":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1820"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1820"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1820"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}