StatNews leads reports of an ongoing saga of Big Insurance controlling healthcare $$ and rationing care.

Michigan's dominant insurer, Blue Cross Blue Shield of Michigan (BCBSM) is also affiliated with NaviHealth, the UnitedHealth contractor named in earlier StatNews reports linked within this article.

https://www.statnews.com/2023/11/14/unitedhealth-algorithm-medicare-advantage-investigation/

UnitedHealth used secret rules to restrict rehab care for seriously ill Medicare Advantage patients

Dec. 28, 2023

 

Health insurance giant UnitedHealth Group used secret rules to restrict access to rehabilitation care requested by specific groups of seriously ill patients, including those who lived in nursing homes or suffered from cognitive impairment, according to internal documents obtained by STAT.

The documents, which outline parameters for the clinicians who initially review referrals for rehab care, reveal that many patients enrolled in Medicare Advantage plans were routed for a quick denial based on criteria neither they, nor their doctors, were aware of.

UnitedHealth kept the restrictions in place until early November, when managers abruptly told frontline clinical reviewers to stop following them and apply more of their own discretion, according to a current employee and internal documents. The directive to toss out the rules coincided with increased scrutiny of Medicare Advantage insurers from federal lawmakers and the Centers for Medicare and Medicaid Services, which will begin auditing their denials of medical services early next year. That scrutiny came after a series of STAT stories exposed UnitedHealth’s practices of pressuring employees to follow an algorithm to cut off care for sick and elderly people already in rehab.

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Casey Ross is a national technology correspondent at STAT. His reporting examines the use of artificial intelligence in medicine and its underlying questions of safety, fairness, and privacy. Before joining STAT in 2016, he wrote for the Cleveland Plain Dealer and the Boston Globe, where he worked on the Spotlight Team in 2014 and was a finalist for the Pulitzer Prize. A Vermont native, he now lives in Ohio with his wife and three children. When he's not with them, he's in his cornfield, cultivating some of the sweetest bi-color in the Midwest.

Bob Herman is a business of health care reporter at STAT. He covers hospitals, health insurance, and other corners of the industry — with a goal of explaining and shining light on the massive amount of money flowing through the system. Prior to joining STAT in 2022, he covered the health care industry at Axios for more than five years. He also previously was an editor and reporter covering health insurance and hospitals at Modern Healthcare. Bob and his family are based in Indiana, so naturally he has a deep love for all things basketball.

A BCBSM FAQ sheet is a window into NaviHealth claims processing.

NaviHealth power is extensive, especially in certain states listed in a May, 2023, UnitedHealthcare announcement.

Q1 What is happening?
UnitedHealthcare has delegated to naviHealth the approval or denial of all initial authorization requests and requests for additional services for post-acute care (PAC) services with home health agencies for certain Medicare Advantage. This will include providing authorization for home health services requested by the following disciplines: physical therapy, occupational therapy, speech therapy, nursing, social work and home health aides.

Q2 What plans are affected by this change?
The delegation applies to members enrolled in UnitedHealthcare Medicare Advantage plans and Dual Special Needs Plans (DSNP). On May 1, 2023, members receiving care in the following states will be delegated to naviHealth: Idaho, Louisiana, Nevada, New Mexico, North Carolina and Washington.

On December 22, Blue Cross Blue Shield of Michigan announced NaviHealth was changing its name to Home & Community Care.