Design Highlights
- Medicare Advantage insurers, like UnitedHealthcare and Humana, have significantly higher denial rates for skilled nursing facility admissions compared to traditional Medicare.
- Automated algorithms and AI tools are increasingly used by insurers to evaluate care eligibility, leading to higher denial rates.
- Financial incentives exist for Medicare Advantage plans to deny nursing home stays, aiming to maximize profits by minimizing service coverage.
- Traditional Medicare typically covers longer nursing home stays (35-44 days), while Medicare Advantage plans limit coverage to just 26 days.
- Two-thirds of skilled nursing providers report daily instances of denied or delayed medically necessary post-acute care, creating access barriers for patients.
In the world of Medicare Advantage, some might say it’s a game of “who can deny care the fastest.” Recent revelations show that these insurers are denying around 13 percent of requests for skilled nursing facility admissions. That’s right—after surgery or severe illness, a significant number of older and disabled Americans find themselves on the wrong end of a denial. It’s almost like a twisted lottery, except there are no winning tickets here.
In Medicare Advantage, denying care feels like a cruel lottery, leaving many vulnerable Americans without necessary support after surgery or illness.
Federal investigators have observed that the major players in this game, like UnitedHealthcare and Humana, are particularly adept at denying rehabilitative care at higher rates than their competitors. It’s like they have a secret club where the entry fee is your health. Prior authorization? Oh, that’s just a fancy term for “let’s make you jump through hoops before we even think about paying for your care.” Two-thirds of skilled nursing providers report that denials or delays for medically necessary post-acute care happen daily. Imagine being a patient needing care and facing a wall of bureaucracy instead of timely treatment.
But wait, it gets better. Insurers have turned to algorithmic tools and artificial intelligence. Yes, machines are now deciding who gets care. Between 2019 and 2022, these tech-savvy insurers ramped up claims denials. They’ve mastered the art of using algorithms to evaluate eligibility, and guess what? Traditional Medicare enrollees are getting more nursing home care than those stuck in the Medicare Advantage maze. Surprise, surprise! Automated decision-making is just a slick way of saying, “Sorry, we’re not paying for that.” In fact, recent reports indicate that some denial rates are as high as 80%.
And let’s talk about the length of stay in nursing homes. Medicare Advantage plans usually cover just 26 days. Traditional Medicare? Between 35 and 44 days. So, while patients are still struggling to get better, insurers are busy figuring out how to push them out the door. Medicare Advantage plans may end nursing home coverage earlier than traditional Medicare allows. Cutting lengths of stay is just one way these companies keep their profits soaring. If you don’t think this is about money, think again.
At the end of the day, Medicare Advantage plans receive a fixed payment to manage care, regardless of the actual needs of patients. This creates a financial motivation to deny services. Denying access becomes a tactic to boost profits. Senate reports have even criticized the big three insurers for limiting access to post-acute care. Strikingly, UnitedHealth’s inpatient rehabilitation denial rate reached 66%, compared to the 41% average among other insurers. So, in this game of care denial, it seems like the only winners are the insurers themselves.
