Senate Permanent Subcommittee on Investigations Releases Majority Staff Report Exposing Medicare Advantage Insurers' Refusal of Care for Vulnerable Seniors

[WASHINGTON, DC] - U.S. Senator Richard Blumenthal (D-CT), Chair of the U.S. Senate Permanent Subcommittee on Investigations (PSI), released a Majority staff report today detailing the Subcommittee's findings thus far in its investigation into the barriers facing seniors enrolled in Medicare Advantage in accessing care. PSI's Majority staff report reveals how the nation's three largest Medicare Advantage insurers-UnitedHealthcare, Humana, and CVS-use prior authorization to target stays in skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals in order to boost their profits.

"Insurance companies say that prior authorization is meant to prevent unnecessary medical services. But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions," said Blumenthal. "In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors-simply to make more money. Our Subcommittee even found evidence of insurers expanding this practice in recent years."

On May 17, 2023, PSI launched its investigation by seeking documents and information from three insurers who together cover nearly 60 percent of all Medicare Advantage enrollees. Today's report presents new findings based on the more than 280,000 pages of documents obtained from these three companies to date.

Through its inquiry, PSI found that between 2019 and 2022, UnitedHealthcare, Humana, and CVS each denied prior authorization requests for post-acute care at far higher rates than they did for other types of care, resulting in diminished access to post-acute care for Medicare Advantage beneficiaries. A summary of PSI's key findings is below.

UnitedHealthcare's Prior Authorization Denial Rate for Post-Acute Care Surged as the Insurer Increasingly Implemented Automated Prior Authorization Processes

According to documents obtained from PSI's investigation, UnitedHealthcare's prior authorization denial rate surged from 10.9 percent in 2020, to 16.3 percent in 2021, to 22.7 percent in 2022. During this time, multiple initiatives were implemented to automate the process.

The company continues to implement initiatives to automate the process. In December of 2022, a UnitedHealthcare working group met to explore how to use AI and "machine learning" to predict which denials of post-acute care cases were likely to be appealed.

CVS Saw a Consistent Correlation Between Increasing Prior Authorization Requirements and Expanding Savings

CVS's prior authorization denial rate for post-acute care remained relatively stable during the period reviewed. However, the number of post-acute care service requests CVS subjected to prior authorization increased by 57.5 percent, far higher than the company's roughly 40 percent growth in enrollment during that period.

Facing pressure to cut costs in the Medicare Advantage division, in April 2021, CVS deployed "Post-Acute Analytics," which used artificial intelligence to reduce the amount of money spent on skilled nursing facilities. A presentation for a March 2022 meeting devoted to prior authorization automation indicated that the insurer had "deprioritized" a plan to reduce the volume of prior authorization because the loss of savings was "too large to move forward."

Humana's Denial Rate for Long-Term Acute Care Hospitals, The Most Expensive Type of Post-Acute Care, Grew By 54 Percent Between 2020 And 2022

Documents obtained by the Subcommittee show that following Humana's relaxing of some prior authorization requirements during the pandemic, two presentations by a senior medical director were given at the company about how requests for long-term acute care hospitals should be evaluated. These presentations, from November and December 2021, included strategies for explaining denials to providers.

Evidence obtained by the Subcommittee to date does not indicate the extent to which Humana may be using automation or predictive technologies to deny prior authorization requests. However, the company has contracted with naviHealth since 2017, and Humana policies suggest contractors may have had greater latitude about predictive technologies.

The Subcommittee continues to investigate the use of predictive technologies by Medicare Advantage insurers. The full Majority staff report detailing PSI's findings thus far is available here.

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