Judith Sullivan, a 76-year-old recovering from major surgery, received a notice from her Medicare Advantage plan that it would no longer pay for her care because she was deemed well enough to go home. However, Sullivan still required assistance to walk and use a colostomy bag. UnitedHealthcare, her insurer, uses a predictive technology tool called “NH Predict” to determine patient discharge dates and anticipated care needs. Patients, providers, and advocates have noticed that these discharge dates often align with the termination of coverage, even if further treatment is necessary. The federal government plans to restrict the use of predictive technology tools by Medicare Advantage plans to make coverage decisions starting next year.
Medicare Advantage plans, which are offered by private insurance companies, provide an alternative to the government-run original Medicare program. While they offer lower costs and additional benefits, such as dental care and transportation, they must adhere to Medicare coverage criteria and cannot deny benefits covered by original Medicare. However, private plans have been found to frequently deny nursing home care, a service that original Medicare would likely cover. Patients like Judith Sullivan and Ken Drost, whose coverage was cut short despite medical evidence supporting their continued need for care, have faced substantial bills and have had to appeal multiple times to receive coverage.
The Centers for Medicare and Medicaid Services will implement new rules in January 2023 to regulate the use of algorithms by Medicare Advantage plans for coverage decisions. Insurers will be required to consider individual circumstances when determining medical necessity rather than relying solely on algorithms or software. Coverage denials deemed not medically necessary must also be reviewed by a healthcare professional with relevant expertise. These changes aim to address concerns about the misuse of predictive technology tools and ensure that coverage decisions are made in the best interest of patients. However, critics question how effectively these rules will be enforced and if penalties for violations are sufficient.
