Are Some Medicare Advantage Plans Using AI to Deny Care? Unfortunately, yes.

Medicare Advantage, deny care, black woman with troubled expression reading a letter/notice

STAT News recently published a series of articles exposing United Health’s misuse of algorithms to cut off rehabilitation care for older and disabled Americans enrolled in their plans, all while having their “profits soar”. In their most recent article, STAT News states:

UnitedHealth Group has repeatedly said its algorithm (generated by UnitedHealth subsidiary NaviHealth), which predicts how long patients will need to stay in rehab, is merely a guidepost for their recoveries. But inside the company, managers delivered a much different message: that the algorithm was to be followed precisely so payment could be cut off by the date it predicted.

Former United Health employees told STAT reporters that “missing the target for patients under their watch meant exposing themselves to discipline, including possible termination, regardless of whether the additional days were justified under Medicare coverage rules.” Furthermore, STAT News’ investigation exposes that NaviHealth “executives have sought to almost entirely subordinate clinical case managers’ judgment to the computer’s calculations” resulting in “inflexible coverage decisions that legal experts say may violate longstanding case law and regulations that govern Medicare benefits.” Coverage decisions, by law, are to be made on a person to person basis based on individual assessment, not an algorithm designed to deny care and bring in ever growing profits for the health insurance company.

United Health, the largest Medicare Advantage (MA) carrier, owns NaviHealth. And the second largest MA carrier, Humana also uses it, as well as many regional carriers. This is a concerning trend given the exposed intents of the NaviHealth executives. And these “intents” have proved incredibly profitable, as STAT News reports that “by restricting the days patients spend in nursing homes, UnitedHealth saves hundreds of millions of dollars every year on their care, increasing profits for one of its most lucrative health insurance products.”

In our partner’s, Center for Medicare Advocacy’s, recent article on this issue, they note that the number of expedited appeals filed to challenge termination of skilled nursing facility services by MA plans more than doubled between 2020 and 2022, which “tracks with increasing enrollment in [MA] plans, and the advent of care management firms using algorithms to scrutinize rehab care.”

This is an important, emerging issue that California Health Advocates and our partners nationwide will continue monitoring. We advocate for increased regulation and supervision of AI use to prohibit and prevent such blatant misuse for profit at the expense of beneficiaries’ health, wellbeing and access to their entitled benefits.

For more information, read Center for Medicare Advocacy’s “Special Report: The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations” (January 2022).

Karen Joy Fletcher

Our blogger Karen Joy Fletcher is CHA’s Communications Director. With a Masters in Public Health from UC Berkeley, she is the online “public face” of the organization, provides technical expertise, writing and research on Medicare and other health care issues. She is responsible for digital content creation, management of CHA’s editorial calendar, and managing all aspects of CHA’s social media presence. She loves being a “communicator” and enjoys networking and collaborating with the passionate people and agencies in the health advocacy field. See her current articles.