After 11 days at a skilled nursing facility in St. Paul, Minnesota, recovering from a fall, 97-year-old Paula Christopherson was told by her insurer that she needed to go home.
But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.
“It seems unethical,” said her daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended her mother’s nursing coverage. The establishment gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or return home.
Health care providers, nursing home representatives and resident advocates say Medicare Advantage plans are increasingly ending member coverage for nursing homes and rehabilitation services before residents patients are healthy enough to return home.
Half of the nearly 65 million people on Medicare are enrolled in private health plans called Medicare Advantage, an alternative to the traditional government program. The plans must cover – at a minimum – the same benefits as traditional health insurance, including up to 100 days of skilled nursing care each year.
But private plans have leeway when it comes to deciding how much nursing care a patient needs.
“In traditional health insurance, health care professionals at the facility decide when someone is safe to go home,” said Eric Krupa, attorney at the Center for Medicare Advocacy, a nonprofit legal group that counsels beneficiaries. “In Medicare Advantage, the plan decides.”
Mairead Paintera vice president of the National Association of State Long-Term Care Ombudsman Programs who runs the Connecticut office, said: “People go to the nursing home and then very quickly get a denial and then they are told to appeal , adding to their stress as they already try to recover.
The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This increases “the potential incentive for insurers to deny access to services and payment in an effort to increase profits,” according to an analysis from april by the Inspector General of the Department of Health and Social Services. Investigators found that care home coverage was among the most often denied services by private plans and often would have been covered by traditional health insurance.
The federal Centers for Medicare & Medicaid Services recently signaled interest in cracking down on wrongful denials of member coverage. In August he asked public comments on how to prevent Advantage plans from limiting “access to medically necessary care”.
The limits on nursing home coverage come after decades of efforts by insurers to reduce hospitalizations, initiatives designed to help cut costs and reduce the risk of infections.
Charlene Harrington, a professor emeritus at the School of Nursing at the University of California, San Francisco and an expert in nursing home reimbursement and regulation, said nursing homes have an incentive to extend residents’ stays. “Length of stay and occupancy are the biggest predictor of profitability, so they want to keep people as long as possible,” she said. Many establishments still have empty beds, a lingering effect of the covid-19 pandemic.
When to leave a nursing home “is a complicated decision because you have two groups that have opposite incentives,” she said. “People are probably better off at home,” she said, if they’re healthy enough and have family members or other sources of support and safe housing. “The resident should have a say in this.”
Jill Sumner, vice president of the American Health Care Association, which represents nursing homes, said her group had “significant concerns” about large Advantage plans cutting coverage. “The health plan can determine how long a person is in a nursing home generally without laying eyes on the person,” she said.
The problem has become “more widespread and more frequent”, said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “It’s not just one plan,” he said. “That’s about all.”
As Medicare Advantage enrollment has grown in recent years, Kumar said, disagreements between insurers and nursing home medical teams have grown. Additionally, he said, insurers have hired companies, such as Tennessee-based naviHealth, that use data about other patients to help predict how much care a person needs at a facility. qualified nursing care according to his state of health. These calculations may conflict with what medical teams recommend, he said.
UnitedHealthcare, which is the largest provider of Medicare Advantage plans, purchased naviHealth in 2020.
Sumner said nursing homes are feeling the impact. “Since the advent of these companies, we have seen shorter lengths of stay,” she said.
In a recent press release, naviHealth said its “predictive technology” helps patients “enjoy more days at home, and healthcare providers and health plans can significantly reduce costs.”
UnitedHealthcare spokeswoman Heather Soule did not explain why the company limited coverage for the members mentioned in this article. But, in a statement, she said such decisions are based on Medicare’s criteria for medically necessary care and involve a review of members’ medical records and clinical conditions. If members don’t agree, she says, they can appeal.
When the patient no longer meets the criteria for coverage in a skilled nursing facility, “it doesn’t mean the member no longer needs care,” Soule said. “That’s why our Care Coordinators proactively engage with members, caregivers, and providers to guide them through an individualized care plan focused on the member’s unique needs.”
She noted that many Advantage plan members prefer to receive care at home. But some members and their advocates say this option isn’t always practical or safe.
Patricia Maynard, 80, a retired Connecticut school cafeteria worker, was in a nursing home recovering from hip replacement surgery in December when her UnitedHealthcare Medicare Advantage plan informed her that she was putting end of cover. His doctors disagreed with the decision.
“If I stayed, I would have to pay,” Maynard said. “Or I could go home and not worry about a bill.” Without insurance, the average daily cost of a semi-private room in his nursing home was $415, according to a 2020 state survey establishment fees. But going home wasn’t practical either: “I couldn’t walk because of the pain,” she says.
Maynard appealed and the company reversed its decision. But a few days later, she received another notice that the plan had decided to stop the payment, again over the objections of her medical team.
The cycle continued 10 more times, Krupa said.
Maynard’s repeat appeals are part of Medicare Advantage’s regular appeal process, CMS spokeswoman Beth Lynk said in a statement.
When an application for the Advantage plan is unsuccessful, members can turn to an independent “quality improvement organization,” or QIO, which handles Medicare complaints, Lynk said. “If a registrant receives a favorable decision from the QIO, the scheme is required to continue to pay for the nursing home stay until the scheme or facility determines that the member or patient no longer needs it” , she explained. Residents who disagree may file another appeal.
CMS could not provide data on how many beneficiaries had nursing home care cut off by their Advantage plans or how many were successful in having the decision overturned.
To help fight denials, the Center for Medicare Advocacy created a form to help Medicare Advantage members file a complaint with their plan.
When UnitedHealthcare decided it wouldn’t pay an additional five days at the nursing home for Christopherson, she stayed at the facility and appealed. When she returned to her apartment, the facility charged her nearly $2,500 for that time.
After Christopherson made repeated calls, UnitedHealthcare reversed its decision and paid for his entire stay.
Loomis said her family remains “mystified” by her mother’s ordeal.
“How can the insurance company deny coverage recommended by their medical care team?” Loomis asked. “They’re the experts, and they deal with people like my mom every day.”
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