For-Profit Medicare Advantage Plans Using AI for Denials Not a Doctor

[cbabe]

https://www.commondreams.org/news/medicare-advantage-2666143830

'This Should Be a National Scandal': For-Profit Medicare Advantage Plans Using AI for Denials

"They're using AI to predict when to cut off payment for treatments," said one watchdog group. "We repeat, AI. Not a doctor."

BRETT WILKINS
Nov 03, 2023

As Medicare Advantage plans rely increasingly upon artificial intelligence to determine—and often deny—payment for patient care, a group of Democratic U.S. lawmakers on Friday urged Medicare's top official to strengthen oversight of AI and algorithmic tools used to make coverage determinations.

"In recent years, problems posed by prior authorization have been exacerbated by MA plans' increasing use of AI or algorithmic software to assist in their coverage determinations in certain care settings, including inpatient hospitals, skilled nursing facilities, and home health," 32 House Democrats led by Rep. Judy Chu (D-Calif.) wrote in a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Books LaSure.

"Advocates and the media report that the use of such software has led to coverage decisions that are more restrictive than allowed under traditional Medicare rules, as well as more frequent and repeated denials of care," the lawmakers wrote. "Absent prohibiting the use of AI/algorithmic tools outright, it is unclear how CMS is monitoring and evaluating MA plans' use of such tools in order ensure that plans comply with Medicare's rules and do not inappropriately create barriers to care."

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Last year, a U.S. Senate probe found that insurance companies and other brokers are "running amok" with "fraudsters and scam artists" making false or misleading claims to dupe senior citizens into purchasing MA plans.

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[MiniMe]

1. If MA spent as much money servicing their clients as they do advertising their plans

maybe they wouldn't need AI to deny coverage. I will never go to a MA because of that.

[XanaDUer2]

2. The plan is to lure seniors

Onto ma, stop Medicare cut benefits. Mark my words.

[LetMyPeopleVote]

3. I hang up on these solicitation calls

The fact that people can pay for these solicitation efforts tell me that these plans are very profitable to so-called insurers and are scams.

[DownriverDem]

4. I wish folks

would just stop attacking MA plans. Not everyone can afford a monthly supplemental plan that doesn't cover prescriptions. We do need M4A, but ignoring the additional benefits from MAs for folks with little income is just sad.

[xmas74]

10. Before they sign up for MA

They need to look at any and all alternatives. I assist with QMBs every day at work. It's a great program for low income.

[Demobrat]

5. I agree that MA can be the best choice for some.

I just wish people were able to make informed decisions based on complete information, which I don’t believe is the case. Yes, the information is there, if you have the skills and resources to go digging for it. But there’s so much hard sell and misinformation people don’t always know what the real trade offs are when they make their choice. That’s wrong.

[anciano]

6. IMO simply putting an out of pocket cap

on Original Medicare parts A and B would help tremendously. For many people that would make Medigap or Advantage plans unnecessary.

[moniss]

8. Yes I remember

when the Gap plans first came in and they were being touted to people as though they were gold. They were the nose of the camel under the tent.

[moniss]

7. This sort of

"pre-determined" denial of benefits has been going on with insurance companies and disability cases for decades. I don't know if SSI has been doing it.

What the insurance companies do with long term disability cases is they pick time periods for payment of benefits and then they cut you off without prior notice and make you "re-qualify" etc. or they claim that they have reviewed your case and you no longer qualify as disabled etc. One might think that the matter could be quickly resolved with a call or report from your doctor but you would be wrong. They drag their feet purposely and the process can take many months if not years. During this time there will be the usual stall tactics like "we didn't receive your documents", "your hearing has been rescheduled" etc. All the while you have no money to pay the bills. It is not uncommon in workers compensation cases for a contested case to take several years beyond when all reports are in.

I've personally known two cases like this. One was workers comp and the other a long term medical disability that was not work related. Now to make matters even worse for the sick and injured the insurance companies who write workers comp policies for the employers, and the non work policies as well, have another tactic they employ to abuse the sick and injured and cut their claims cost. These companies typically know everything about you such as your marital status, children, work and basic financial condition. In the case of private policies they ask all of this on the application and during their determination to issue a policy.

So let's say they've been paying your monthly benefit for about 18 months of a 60 month benefit period. They know which cases have claimants who are struggling for money even with the disability payment. They know you have children. Christmas is coming. Now comes the phone call from the insurance adjuster who says he is just calling to check in and see how it's going. Of course you are dealing with a financial situation and a disability which may be affecting your marriage as well. So the "sympathetic" adjuster says he's sorry this has all happened to you but maybe he can help. He tells you that he could give you a lump sum 18 payments all at once if you'll agree to settle the entire claim for that amount. Your lenders/credit cards aren't available to you and you know you are facing not having money for Christmas for your wife and kids. So they know that in many cases you take the money and the company saves big time by cutting the claim nearly in half.

It was no "just checking in" phone call. After you the guy moves on to the next call. If the company were really trying to help you they could offer to give you a few payments accelerated now and then end the scheduled payments by an equal number of months at the tail end of the benefit period. That's what a caring human being would do. But we're talking about insurance companies and the subhuman thing known as an insurance adjuster. People say "it's just my job". Maybe so but it doesn't make it right. It doesn't mean you aren't lower than pond scum.

[moniss]

9. When you talk to these jokers

about MA and ask them if this is a private insurance policy they twist themselves in knots to try and deny it and they keep saying "it's Medicare" but it is not Medicare. Medicare is a government funded/controlled benefits program. MA is a private insurance policy that mimics the benefits/coverage of Medicare and may have other benefits that Medicare does not. But it is also allowed to have restrictions that Medicare does not. Restriction of doctors, out of network costs etc. If you push them hard enough about being private insurance they may break down and admit it but maybe not. There is a reason they can only sign you up after you talk to a registered insurance agent on the phone. It's because it is private insurance and not the same thing as Medicare. In other words this confusing crap about being "part C" is just meant to cloak what is really happening. You do not have Part A, Part B, Part C and Part D. Part C means you don't have A and B and D anymore. You have C which is a private insurance policy administered to deny and reduce claims in order to make the insurance company as much money as possible.

The danger also is that once you switch to C and then want to switch back to Medicare you can be medically underwritten and have to pay a higher than normal monthly premium. I have a friend who had C and underwent a knee replacement. He had to go to "their guy" otherwise he would have to pay a huge amount of the cost. So "their guy" was sort of the bargain basement guy that many people complained about and the results after surgery have been very problematic for him. But he learned the hard way and he fought to get back to Medicare and can now go to any doctor he wants without restriction or increased cost.

[meow2u3]

11. Medicare Advantage is a scam

I always say Medicare Advantage is designed to take advantage of people on Medicare.