Capitol Building in Washington, DC

A senator’s recent tough language regarding Medicare Advantage plan prior authorizations was a welcome sign for National Association for Home Care & Hospice President William Dombi.

“We are very encouraged with the Senate’s attention on Medicare Advantage claims processes,” he told McKnight’s Home Care Daily Pulse. “Home health agencies have suffered through retroactive claim denials with an application of technical standards on claims that were previously unknown to the providers. We hope that positive changes come as a result of this congressional oversight.”

Sen. Richard Blumenthal (D-CT) put MA plans on notice last week at a Senate subcommittee hearing: “If you deny life-saving coverage to seniors, we are watching. We will expose you. We will demand better. We will pass legislation if necessary. But action will be forthcoming.”

Blumenthal said there is “growing evidence” that MA insurance companies are relying on algorithms, as opposed to doctors or other clinicians, to make decisions on whether or not deny patient care. He and other lawmakers have requested documents from CVS-Aetna, UnitedHealth and Humana — which combined cover more than 50% of MA beneficiaries — showing how coverage determinations are made.

“The insurers may refer to these algorithms as tools used for guidance, but the denials they generate are too systematic to ignore. All too often, black box AI [and algorithms] have become a blanket mechanism for denial,” he said. 

Blumenthal also noted the strong incentives for MA plans to continue requiring prior authorizations. 

“Insurers are, in effect, denying Americans necessary care in order to fatten and pad their bottom lines, and that phenomenon is unacceptable,” he said.

A recent survey of medical groups showed that 97% of patients enrolled in MA have experienced delays or denials of medically necessary care due to prior authorization requirements. MA enrollment now accounts for more than 50% of beneficiaries.