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After 11 days in a St. Paul, Minnesota, skilled nursing facility recuperating from a fall, Paula Christopherson, 97, was told by her insurer that she should return home.<\/p>\n
But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn\u2019t well enough to leave.<\/p>\n
\u201cThis seems unethical,\u201d said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother\u2019s nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company\u2019s decision, or go home.<\/p>\n
Healthcare providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members\u2019 coverage for nursing home and rehabilitation services before patients are healthy enough to go home.<\/p>\n
Half of the nearly 65 million people with Medicare are enrolled in the private health plans called Medicare Advantage, an alternative to the traditional government program. The plans must cover \u2014 at a minimum \u2014 the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care every year.<\/p>\n
Read more:\u00a0 But the private plans have leeway when deciding how much nursing home care a patient needs.<\/p>\n \u201cIn traditional Medicare, the medical professionals at the facility decide when someone is safe to go home,\u201d said Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. \u201cIn Medicare Advantage, the plan decides.\u201d<\/p>\n Mairead Painter, a vice president of the National Association of State Long-Term Care Ombudsman Programs who directs Connecticut\u2019s office, said, \u201cPeople are going to the nursing home, and then very quickly getting a denial, and then told to appeal, which adds to their stress when they\u2019re already trying to recuperate.\u201d<\/p>\n The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This raises \u201cthe potential incentive for insurers to deny access to services and payment in an attempt to increase profits,\u201d according to an April analysis by the Department of Health and Human Services\u2019 inspector general. Investigators found that nursing home coverage was among the most frequently denied services by the private plans and often would have been covered under traditional Medicare.<\/p>\n Not a Modern Healthcare subscriber? Sign up today.<\/em><\/strong><\/p>\n The federal Centers for Medicare & Medicaid Services recently signaled its interest in cracking down on unwarranted denials of members\u2019 coverage. In August, it asked for public feedback on how to prevent Advantage plans from limiting \u201caccess to medically necessary care.\u201d<\/p>\n The limits on nursing home coverage come after several decades of efforts by insurers to reduce hospitalizations, initiatives designed to help drive down costs and reduce the risk of infections.<\/p>\n Charlene Harrington, a professor emerita at the University of California-San Francisco\u2019s School of Nursing and an expert on nursing home reimbursement and regulation, said nursing homes have an incentive to extend residents\u2019 stays. \u201cLength of stay and occupancy are the main predictor of profitability, so they want to keep people as long as possible,\u201d she said. Many facilities still have empty beds, a lingering effect of the COVID-19 pandemic.<\/p>\n When to leave a nursing home \u201cis a complicated decision because you have two groups that have reverse incentives,\u201d she said. \u201cPeople are probably better off at home,\u201d she said, if they are healthy enough and have family members or other sources of support and secure housing. \u201cThe resident ought to have some say about it.\u201d<\/p>\n Jill Sumner, a vice president for the American Health Care Association, which represents nursing homes, said her group has \u201csignificant concerns\u201d about large Advantage plans cutting off coverage. \u201cThe health plan can determine how long someone is in a nursing home typically without laying eyes on the person,\u201d she said.<\/p>\n The problem has become \u201cmore widespread and more frequent,\u201d said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. \u201cIt\u2019s not just one plan,\u201d he said. \u201cIt\u2019s pretty much all of them.\u201d<\/p>\n As Medicare Advantage enrollment has spiked in recent years, Kumar said, disagreements between insurers and nursing home medical teams have increased. In addition, he said, insurers have hired companies, such as Tennessee-based naviHealth, that use data about other patients to help predict how much care an individual needs in a skilled nursing facility based on her health condition. Those calculations can conflict with what medical teams recommend, he said.<\/p>\n UnitedHealthcare, which is the largest provider of Medicare Advantage plans, bought naviHealth in 2020.<\/p>\n Sumner said nursing homes are feeling the impact. \u201cSince the advent of these companies, we\u2019ve seen shorter length of stays,\u201d she said.<\/p>\n In a recent news release, naviHealth said its \u201cpredictive technology\u201d helps patients \u201cenjoy more days at home, and healthcare providers and health plans can significantly reduce costs.\u201d<\/p>\n UnitedHealthcare spokesperson Heather Soule would 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\u2019s criteria for medically necessary care and involve a review of members\u2019 medical records and clinical conditions. If members disagree, she said, they can appeal.<\/p>\n When the patient no longer meets the criteria for coverage in a skilled nursing facility, \u201cthat does not mean the member no longer requires care,\u201d Soule said. \u201cThat is why our care coordinators proactively engage with members, caregivers, and providers to help guide them through an individualized care plan focused on the member\u2019s unique needs.\u201d<\/p>\n She noted that many Advantage plan members prefer receiving care at home. But some members and their advocates say that option is not always practical or safe.<\/p>\n Patricia Maynard, 80, a retired Connecticut school cafeteria employee, was in a nursing home recovering from a hip replacement in December when her UnitedHealthcare Medicare Advantage plan notified her it was ending coverage. Her doctors disagreed with the decision.<\/p>\n \u201cIf I stayed, I would have to pay,\u201d Maynard said. \u201cOr I could go home and not worry about a bill.\u201d Without insurance, the average daily cost of a semiprivate room at her nursing home was $415, according to a 2020 state survey of facility charges. But going home was also impractical: \u201cI couldn\u2019t walk because of the pain,\u201d she said.<\/p>\n Maynard appealed, and the company reversed its decision. But a few days later, she received another notice saying the plan had decided to stop payment, again over the objections of her medical team.<\/p>\n The cycle continued 10 more times, Krupa said.<\/p>\n Maynard\u2019s repeated appeals are part of the usual Medicare Advantage appeals process, said Beth Lynk, a CMS spokesperson, in a statement.<\/p>\n Download Modern Healthcare\u2019s app to stay informed when industry news breaks<\/em><\/strong>.<\/strong><\/p>\n When a request to the Advantage plan is not successful, members can appeal to an independent \u201cquality improvement organization,\u201d or QIO, that handles Medicare complaints, Lynk said. \u201cIf an enrollee receives a favorable decision from the QIO, the plan is required to continue to pay for the nursing home stay until the plan or facility decides the member or patient no longer needs it,\u201d she explained. Residents who disagree can file another appeal.<\/p>\n CMS could not provide data on how many beneficiaries had their nursing home care cut off by their Advantage plans or on how many succeeded in getting the decision reversed.<\/p>\n To make fighting the denials easier, the Center for Medicare Advocacy created a form to help Medicare Advantage members file a grievance with their plan.<\/p>\n When UnitedHealthcare decided it wouldn\u2019t pay for an additional five days in the nursing home for Christopherson, she stayed at the facility and appealed. When she returned to her apartment, the facility billed her nearly $2,500 for that period.<\/p>\n After Christopherson made repeated appeals, UnitedHealthcare reversed its decision and paid for her entire stay.<\/p>\n Loomis said her family remains \u201cmystified\u201d by her mother\u2019s ordeal.<\/p>\n \u201cHow can the insurance company deny coverage recommended by her medical care team?\u201d Loomis asked. \u201cThey\u2019re the experts, and they deal with people like my mother every day.\u201d<\/p>\n Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.<\/i><\/p>\n<\/div>\n
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