The use of artificial intelligence (AI) in healthcare is capturing headlines as a potential tool to streamline operations and predict patient needs for favorable health outcomes, among other things.[1] The Center for Medicare Advocacy, however, has increasingly become aware of how AI-powered decision-making tools may be used by Medicare Advantage (MA) plans to make coverage decisions. Those decisions may be more restrictive than Medicare coverage guidelines, potentially leading to premature terminations of coverage or continuation of care for beneficiaries.[2]
The Center recently published a report, The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations, which outlined areas of growing concerns. Issues around the use of AI have also been highlighted by the Commonwealth Fund as part of a series of blogs focusing on different aspects of the MA program.[3] A recent blog post noted, “A related concern is that plans are using proprietary, algorithm-driven systems to make decisions (including those requiring prior authorization) about approving coverage for services.”[4]
The issues around prior authorization and persistent denials of coverage potentially have devastating impacts on patients. The Center is hearing alarming cases of Medicare beneficiaries suffering from impacts of AI decision-making tools despite the fact that Medicare is adamant that no claim should be based on a screening tool alone.[5] Furthermore, Medicare requires an individualized assessment of each beneficiary’s qualification for coverage in certain care settings.[6] The AI tools, however, provide recommendations based on previous patient experiences.
One beneficiary in Connecticut, Ms. M, was hospitalized after she underwent a hip replacement. The 80-year-old was transferred to a skilled nursing facility (SNF) for short-term rehab. Ms. M’s UnitedHealthcare Medicare Advantage plan touts that it offers coverage of unlimited days in a SNF.
Ms. M’s goal in the nursing home was to reach a level of independence that would allow her to return home where she lived on her own prior to the surgery. Her recovery in the SNF, however, was hindered due to various complications such as a nerve injury and becoming infected with COVID-19. Nevertheless, Ms. M was still able to make progress consistent with the goals set out in the physical and occupational therapy evaluations. According to Paula Haney, the Director of Rehabilitation at the SNF, Ms. M. was still benefiting from her skilled therapy regimen and, therefore, continued to meet Medicare coverage criteria.
Despite this fact, Ms. M has been forced to battle UnitedHealthcare for continued coverage of her three-month stay at the facility. While trying to regain mobility after her hip operation, Ms. M filed ten appeals on UnitedHealthcare’s repeated decisions to terminate her coverage.
Paula Haney explained to the Center that these frequent denials have increased for her patients, “I have never experienced the number of denials that we have received. The frustrating part is that we have overturned so many of those denials and yet they keep coming.”
Ms. M reached out to the Center after filing the ten successful appeals on her own. The Center contacted both United Healthcare and their subsidiary naviHealth, a post-acute case management company tasked with determining when to terminate coverage, to find out more about how these decisions were being made. After finally agreeing to meet with the Center and Haney, naviHealth’s clinical representative continued to offer multiple explanations as to why coverage should be terminated, including: Ms. M’s goal of returning home was unrealistic and that the therapy she was receiving could be provided by someone who was not skilled.
According to Haney, naviHealth provides similar explanations for their other denials. “Basically, what we’re hearing is either the patient is not making adequate progress, or the patient has reached a level that should not require skilled services. There isn’t a whole bunch of clarification.”
Haney recounted to the Center how the repeated denials of coverage impacted patients. “They’re dealing with trying to get better. And it’s this emotional roller coaster every five to seven days.” Ms. M doesn’t have the financial means to privately pay for continued short-term rehab and the weekly denials took a serious emotional toll. “She would come down here and be a wreck. She’d be weeping. Just so worried. ‘What’s going to happen? Are they going to take my house? What do I do now?’”
Despite her Medicare Advantage plan stating it covered unlimited days in a SNF, Ms. M received less than a month of coverage before the barrage of terminating notices began. Unfortunately, Ms. M’s case is not unique, but her fighting spirit is. According to a 2018 Office of the Inspector General report, beneficiaries and providers appealed only one percent of the Medicare Advantage denials between 2014 and 2016.[7]
“We’ve had a couple of people who have gone home and ended up back in the hospital. And we’ve seen them again,” according to Haney. “We’re happy to see them if they need us, but we really would rather have it if they had gotten a little bit stronger, maybe they would have been able to avoid that rehospitalization.”
The Center continues to investigate AI-powered decision coverage issues and will provide updates as we learn more.
Unfortunate update: Kepro, the independent adjudicator of Ms. M’s appeals, has finally upheld naviHealth’s Notice of Medicare Non-Coverage despite her continuing to receive therapy each weekday.
April 21, 2022 – C. St. John and E. Krupa
[1]Landau, J. The pluses and minuses of AI in Healthcare. Fast Company. (Feb. 28, 2022). Available at: https://www.fastcompany.com/90723569/the-pluses-and-minuses-of-ai-in-healthcare
[2] Saxena, L. Center for Medicare Advocacy Special Report: The Role of AI-powered Decision-Making Technology in Medicare Coverage Determinations. Center for Medicare Advocacy. (Jan. 19, 2020). Available at: https://medicareadvocacy.org/center-for-medicare-advocacy-special-report-the-role-of-ai-powered-decision-making-technology-in-medicare-coverage-determinations/
[3] CMA. Commonwealth Fund Blog Series About Medicare Advantage. (Apr. 7, 2022). Available at: https://medicareadvocacy.org/commonwealth-fund-blog-series-about-medicare-advantage/
[4] Hostetter, M., & Klein, S. Taking Stock of Medicare Advantage: Benefit Design. Commonwealth Fund. (Mar. 31, 2022). Available at: https://www.commonwealthfund.org/blog/2022/taking-stock-medicare-advantage-benefit-design
[5] Saxena, L. Center for Medicare Advocacy Special Report: The Role of AI-powered Decision-Making Technology in Medicare Coverage Determinations. Center for Medicare Advocacy. (Jan. 19, 2020). Available at: https://medicareadvocacy.org/center-for-medicare-advocacy-special-report-the-role-of-ai-powered-decision-making-technology-in-medicare-coverage-determinations/
[6] CMS. Frequently Asked Questions (FAQs) Regarding Jimmo Settlement Agreement. (Updated Dec. 1, 2021) Available at: https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQs
[7] OIG. Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials. (OEI-09-16-00410) 09-25-2018. Available at: https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp