Poliakoff & Associates, P.A. Medicare, senior care, Tort Reform No Comments

Medicare Advantage Death Panels

Medicare insurers have widely varying rejection rates for patients seeking nursing-home stays. This is also true for long-term care hospitals and inpatient rehabilitation facilities, according to two new reports from the Office of Inspector General for the Department of Health and Human Services.

Among the most likely to initially refuse access to the costly facilities are Medicare insurers with the biggest enrollments, UnitedHealth Group, CVS Health’s Aetna and Humana.

For these companies, denial rates hovered around 13% for nursing-home care. As for patients seeking to be admitted to long-term-care hospitals though, initial rejection rates were as high as 80%. This is well above the industry average of 65%, which is still an incredibly high rate of rejection.

While seniors enrolled in traditional Medicare generally have no need for preapproval, private insurers who offer Medicare Advantage plans have long said that their preapproval requirements ensure patients don’t receive unnecessary or harmful care.

Still, Rosemary Bartholomew, a lead author for both reports, said the findings “raised concerns that some patients may have been denied medically necessary care.”

Perhaps even more concerning is the 40% denial for nursing home residents seeking more intensive care in a skilled nursing facility.

The two new reports from the inspector general, which focused on data for June 2024 and included the 19 largest Medicare insurers, come while the industry is making public promises to reduce and streamline prior authorizations for care, long a grievance for doctors and patients.

Perhaps Medicare insurers realize the serious mistakes they are making in denying such high percentages of requests for care. In fact, when enrollees appeal their denials, insurers overturn the previous rejection and provide authorization 95% of the time.

Unfortunately, most enrollees do not appeal. As a result, the Medicare plan seniors choose has a major impact on whether they can get the nursing-home care they need.