WASHINGTON — Insurance was the last thing on Vicki’s mind when she traveled across the country to be with her mom, who had just gotten into a car accident.
“She's 80 years old, she suffered a fractured pelvis as a result primarily of the air bag,” Vicki said. “She was transported to the hospital and, fortunately, did not need surgery.”
Instead of surgery, her mother’s doctors recommended inpatient rehabilitation. But that treatment was denied by her Medicare Advantage plan.
“They didn't really give an explanation,” she said. “I guess they just didn't think it was necessary.”
Vicki said her mother’s doctor filed an appeal but was denied. The family worked with a case manager on another appeal, but that was also rejected.
“It was like red tape after red tape,” Vicki said. “So finally we just gave up.”
Vicki’s family story is similar to the many Christine Huberty hears daily.
“In one case, there was a stroke victim who lost about a month's worth of therapies and progress because he was dealing with this appeals process,” Huberty told Spectrum News. “So even his doctors — in the doctor's notes — said he would have gotten home earlier, and probably progressed better had he not lost about a month of his life trying to deal with these appeals.”
Huberty, a Madison-based attorney for the Greater Wisconsin Agency on Aging Resources, helps beneficiaries with appeals. She said she’s seen a surge in cases in the last few years.
“I'd say even in just the last week, we received four of these cases, and some of them we won't be able to take because we're only five attorneys, we can't take all of these,” she said. “I truly worry about the rest of the people in Wisconsin who this happens to and they can't appeal. They don't know how or they give up. And nationally, too. I truly worry about all the people that are negatively impacted and harmed as a result of these denials."
Some members of Congress share that concern. Last week, lawmakers put some MA insurers on notice, warning they must follow Medicare’s coverage rules related to delays and denials of care patients need.
“If you deny life-saving coverage to seniors, we are watching. We will expose you,” Sen. Richard Blumenthal, D-Conn., Chairman of the Senate Permanent Subcommittee on Investigations, warned during a hearing last week.
Sen. Blumenthal announced the panel sent letters to Humana, CVS Aetna and UnitedHealthcare — three of the top MA plans — demanding information on their decision-making processes around patient denials. The senator said reports that the companies were relying on AI technology to reject patients’ claims also prompted the probe.
“The fight for insurance coverage is detracting from the fight for their health,” Sen. Blumenthal said during the hearing. "And perhaps most troubling of all, there is growing evidence that insurance companies are relying on algorithms rather than doctors or other clinicians to make decisions to deny patient care.”
Huberty testified during last week’s Senate hearing, pressing members of Congress to increase oversight.
“We have these privatized health plans, you know, sold as a Medicare product that have little to no oversight,” Huberty said. “They're supposed to be offering the same exact coverage and standards applying the same standards as the original Medicare piece. And they're not.”
Sen. Blumenthal threatened regulatory legislation down the road if the Senate’s probe finds the insurers prioritized profit over patients. But another witness during the hearing, Lisa Grabert, a visiting Research Professor at Marquette University College of Nursing, said recently approved rules by the Center for Medicare and Medicaid Services could address the surge in patient care denials without legislative intervention.
"Prior to this past April, it wasn't really clear, at least in the form of formal written policy, what constituted the rules for prior authorization. Now, it's pretty clear,” Grabert told Spectrum News. “It's probably an area where we needed a little bit of oversight. And I do think as a result of it, we will see some behavior changes and plans concentrating on different things and possibly different services moving forward now that we've had the hearing, and CMS has articulated some fine print regulations.”
While Vicki’s mom’s situation was eventually resolved, she hopes sharing her story could help others.
“My mom has two college educated daughters, and it was still like a maze to try to figure this out,” she said. “We have a lot of seniors out there that maybe don't have people to help them navigate the process.”
Editor’s Note: At Vicki's request, Spectrum News is not disclosing the insurer or her last name for privacy reasons.