Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care
US Senate Permanent Subcommittee on Investigations Majority Staff Report
Every day, doctors evaluate thousands of seniors recovering from falls, strokes, and other ailments, and enter a recommended course of treatment into an online portal, or in some cases feed it into a fax machine. But whether the requested service is determined to be medically necessary is a decision that belongs to people at the other end of the line. This is prior authorization. And for beneficiaries of Medicare Advantage, the alternative to Traditional Medicare in which private companies contract with the government to administer health plans, it has become not just a bureaucratic maze, but a potential threat to their health.
On May 17, 2023, the Permanent Subcommittee on Investigations (“PSI” or “the Subcommittee”) launched an inquiry into the barriers facing seniors enrolled in Medicare Advantage in accessing care. PSI sought documents and information from the three largest Medicare Advantage insurers: UnitedHealthcare, Humana, and CVS, who together cover nearly 60 percent of all Medicare Advantage enrollees. This report presents new findings based on the more than 280,000 pages of documents obtained from these three companies to date.
The magnitude and scope of prior authorization requests and denials for particular types of care has been undisclosed before now. This Majority staff report reveals how Medicare Advantage insurers are intentionally using prior authorization to boost profits by targeting costly yet critical stays in post-acute care facilities. Insurer denials at these facilities, which help people recover from injuries and illnesses, can force seniors to make difficult choices about their health and finances in the vulnerable days after exiting a hospital.
Among the Subcommittee’s new findings:
• 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.
• In 2022, both UnitedHealthcare and CVS denied prior authorization requests for postacute care at rates that were approximately three times higher than the companies’ overall denial rates for prior authorization requests. In that same year, Humana’s prior authorization denial rate for post-acute care was over 16 times higher than its overall rate of denial.
PSI also obtained internal documents that provide insight into each company’s use of the prior authorization, including the role of automation and predictive technologies.
PSI found that:
• UnitedHealthcare’s prior authorization denial rate for post-acute care surged from 10.9 percent in 2020, to 16.3 percent in 2021, to 22.7 percent in 2022. During this time, it was implementing multiple initiatives to automate the process.
• 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.
• 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, after it held training sessions devoted to prior authorization requests for that type of facility.
While the Subcommittee continues to investigate the use of predictive technologies by Medicare Advantage insurers, the data obtained so far is troubling regardless of whether the decisions reflected in the data were the result of predictive technology or human discretion. It suggests Medicare Advantage insurers are intentionally targeting a costly but critical area of medicine—substituting judgment about medical necessity with a calculation about financial gain.
