Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need

[usonian]

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/
Tons here.
• "Medicare Advantage" makes it possible.
• "The Algorithm" makes decisions

Patients thrown under the bus.
Long and worth reading.

NaviHealth started making its sales pitch to Medicare Advantage plans: Let us manage every piece of your members’ care for the first 60 to 90 days after they are discharged from the hospital, and we’ll all share in any savings.

The sweetener was the technology. One of the company’s core products is an algorithm called nH Predict. It uses details such as a person’s diagnosis, age, living situation, and physical function to find similar individuals in a database of 6 million patients it compiled over years of working with providers. It then generates an assessment of the patient’s mobility and cognitive capacity, along with a down-to-the-minute prediction of their medical needs, estimated length of stay, and target discharge date.

...

In interviews, doctors, medical directors, and hospital administrators described increasingly frequent Medicare Advantage payment denials for care routinely covered in traditional Medicare. Many said their attempts to get explanations are met with blank stares and refusals to share more information. The black box of the AI has become a blanket excuse for denials.

“They say, ‘That’s proprietary,’” said Amanda Ford, who facilitates access to rehabilitation services for patients following inpatient stays at Lowell General Hospital in Massachusetts. “It’s always that canned response: ‘The patient can be managed in a lower level of care.’”

"But the algorithm!!!"

[sarcasmo]

1. AI sounds Republican.

[ariadne0614]

11. IOW, profit-driven.

For the eleventy millionth time, so-called Medicare so-called Advantage is NOT Medicare. Aside from a paltry number of non-profit policies, it is PRIVATE INSURANCE. The “advantage” goes to the insurance companies, once they lure enough people away from traditional Medicare to the point where it’s weak enough to drown in a bathtub. Then we each get sucked down the drain when the algorithm decides.

[SheltieLover]

2. Kicking for Visibility

[EYESORE 9001]

3. 'That's proprietary'

In other words, there would be a public outcry of the highest order if we revealed our life-or-death algorithm.

[Renew Deal]

4. Everything programmatic is AI

AI might be used as a term to confuse or deceive. The outcomes are based on human programming of the system.

And yes, "black box" decision making is ethically questionable at best. The problem here isn't the computers. It's the people that told them what to do.

[The Unmitigated Gall]

5. Wow. An AI "death panel".

[keithbvadu2]

10. Good one!

[Kota]

6. just had to deal with Navi health for my mother's rehab in a nursing home.

Went thru the appeals process, nothing worked, finally went to the attorney general's health site, filed a complaint. Navi care approved everything immediately. It was clear to me that they weren't even reading my appeals. Otherwise, they would have never let an 87 yr old go home who had only gotten elbow cast off 3 days before and was mostly bedridden with 5 broken bones in her pelvic. They just kept saying statistically she could go home.

[getagrip_already]

7. as I rapidly approach 65......

I'm bewidered by the options after a and b. I'm still working, but under my plan I'll still have to apply for medicare a since that will become primary and my company policy will pick up the rest.

But I am really confused what I should do if I stop working. If I get laid off, I very seriously doubt I wll bother to get nother job. I've had it with day to day work and have enough saved to live on comfortably.

But really, I haven't a clue what I would choose if I had to do it today.

[Lonestarblue]

12. Please look carefully at original Medicare. The Advantage plans are insurance profit centers.

Advantage is not actually Medicare. It is another form of insurance that gets money from the Medicare Fund for those who are eligible for Medicare, and they have been costing much more per person than original Medicare. One of the primary differences is that the Advantage plans typically cover some level of vision and dental care.

When I was choosing, my concern was the insertion of insurance executives deciding care instead of doctors. With Advantage plans, your doctor has to get approval for your treatment. With original Medicare, there is no one between you and your doctor making your healthcare decisions.

You pay monthly premiums for both Advantage and Medicare, but Advantage plans are typically leas expensive because they are trying to grow their share of seniors on their plans. If they get enough, they will have essentially turned Medicare into private insurance with coverage of treatment completely at the whim of for-profit insurance companies.

The options after Parts A and B are called Medigap or supplemental insurance that covers the co-pays and the costs that original Medicare does not cover, plus coverage for prescription drugs. These supplemental insurance programs are not Advantage. If you speak with an insurance agent, you’ll get a hard sell to go with an Advantage plan because that’s where they make their money.

As you can tell, I am not an Advantage fan because its goal is to privatize senior healthcare, at which point our healthcare will be sacrificed for more profits.

Good luck!

[dflprincess]

14. Anyone tempted to sign up for an Advantage plan

Needs to ask themselves why the insurance companies spend millions pushing Advantage and never talk about Gap policies. Hint: it's not because they care about you.

[Big Blue Marble]

13. If feels overwhelming at first.

Most importantly, stay away from Part C that is Advantage Care. These are private profit-based insurance.

Stick with Traditional Part A, B, and D all part of the traditional Medicare.

Part A is covered by your past contributions and covers all care in hospital.
Part B is for outpatient care and covers 80% of costs. You will need supplement private insurance
to cover the additional costs (20%). These plans are standardized plans across companies.
You can chose the plan the best fits your needs.

Part D is for drug coverage.

Traditional may seem to be a little more expensive but over time will cost you less.
It will give you far more control over your health care as you age and more choice
of providers and medical care when you need it.

[1WorldHope]

15. I had no idea that Advantage plans were privatized Meicare.

I worked in human services for 30 years. When I went with people to sign up at the department of insurance SHIIP, they always recommended an advantage plan. I didn't see the point of paying for a supplement plus part D for meds. My premium is $0 and the deductable is around $3,500. I was always self employed for many years I had no insurance. When the ACA was passed I got reasonable insurance. So, I just trusted the advantage plans. Then I suggested my 95 year old neighbor quit paying so much for a supplement. She switched plans, then fell down and had to go to the hospital. They sent her to skilled nursing and that there was the problem. They kicked her out before she was ready because the advantage plan is very limited. Her family struggled to care for her in her home, but, just couldn't do it. They sent her to a nursing home where she caught covid twice. She only lived about 6 months. When she died at the nursing home they found 5 fentanyl patches on her back. Which has nothing to do with the insurance plan but, losing skilled nursing turned out to be her demise. Sad. But, is too late for me now to switch back and I don't want to pay 1/3 of my SS check to have a traditional plan.

[ProfessorGAC]

33. As Others Said...

...have a jaundiced eye toward Part C.
We went traditional Medicare, with a Supplemental. It's a little more expensive, but the piece of mind is more than worth the delta.
Some companies even base supplemental costs relative to income (which, alas, doesn't apply to us.)
Our dental plan costs a bit more than some Part C offerings, but the dentist 2 blocks away accepts it. The convenience is worth the $10 or so bucks per month difference.
The profit motive of Part C makes me skeptical about the true value compared to traditional Medicare.
BTW: I've only been on Medicare for 18 months. The only thing I noticed different than my individual policy (I retired at 62 so I had to carry my own coverage) is that it's cheaper. It's just as straightforward & understandable as prior.

[WiVoter]

8. Algorithms Should Be Eliminated

Just my opinion

[Runningdawg]

9. I'm 63 I don't believe I will ever see a penny of SS and won't live to Medicare age.

I've already been diagnosed with 2 serious conditions; I know that I will die without future medical care. I've been sent home from the ER to hospice care twice since 1-23 LOL yeah, my insurance doesn't cover that....
Pain pills? Sure, here are 3. Therapist? The insurance doesn't cover that either.
Now the best I can hope for is one quick, massive, life-ending event.

[1WorldHope]

16. Now that is some sad shit to hear. Could you qualify for Medicaid now?

Medicaid would pay for all those needs you spoke of. Call your Aging services and see if they can help. 🤞

[Runningdawg]

21. I just watched a friend go through the process. He was homeless before he saw any money

and dead in a nursing home that took all of it 3 months later. Never heard of "aging service" and I've got less than a year left, it's not worth the hassle. I want to spend my final days sitting on the porch with my dogs, not wasting time running from one office to the next in hope someone will throw me a bone.

[1WorldHope]

27. I get it. I don't know where you live, but aging services is a federal program that covers the whole

country. They can also come to you. But sitting on the front porch with the dogs is the best way to spend any day. I wish a miracle of good things to rain down on you. ✌️

[progressoid]

18. ...

So sorry.

Our medical system is awful.

[getagrip_already]

25. you can start collecting early ss benefits..

I believe the age is 62.5. You will get less than if you wait until 67, but who cares. You actually have to live until 79 for it to be worth waiting till you are 67.

Apply now.

[TygrBright]

17. Yet another reason to slog through the difficult process of getting regular Medicare.

They make getting "Advantage" plans incredibly easy, with sales people pestering you from six months to the day before you turn 65. They send snail mail, they call, they offer "free" consultations and "assistance" navigating your Medicare startup, they have glitzy sales materials and they'll walk you through every step of the process with wonderful helpfulness.

They have endless patience with your questions and will comb through databases and plan guides to determine exactly what particular thing is theoretically covered at what level under what circumstances and for how long. They'll compare pharmacopeias and coverage levels between Advantage plans for particular medications. They'll identify network providers for you and help you figure out whether your specialist is in-network for which plans for hours on end, if need be. They'll do whatever it takes to get you to sign up...

...until you tell them you don't want an Advantage plan, you just want plain old Medicare. Part A and Part B, plus a Part D for prescription drug coverage and maybe a Medigap supplemental plan.

They'll try to talk you out of it by pointing out all the "extras" that the Advantage plans offer, and how CHEAP they are and how EASILY everything can be set up and "customized" for you, and it's all combined into ONE plan, no need to manage Part B plus Part D plus a supplemental plan, just one plan, one payment, and easy-peasy extra stuff!

And if you say "Nope, just want Medicare, Part A and Part B, plus Part D for prescriptions and maybe a Medigap supplemental plan" they drop you like a hot potato and leave you to the mercy of government websites where the most help you get is FAQ pages and plan comparison pages, but no live human beings to actually answer your questions.

But it's still worth it. Stick with it. Use the government sites. Put up with the inconvenience of having to wait and spend another couple of months going back and forth to get your auto-pay set up for Part B. Once you are signed up for "real" Medicare, you're in charge of your care, there are no networks to traverse, no pre-authorizations to see a specialist, etc. Yes, sometimes it can be hard to find a provider with a caseload that will allow them to take another Medicare patient, but it's still WAY easier than navigating the thorny thickets of "Advantagedom" where AI monsters lurk everywhere.

helpfully,
Bright

[MissB]

19. well said!!!

Dh will hit the magic number long before I do, but I've already told him what his choice is for Medicare vs Medicare Advantage.

My mom is quite happy with her Medicare Advantage plan, but I can guarantee that they kicked her out of the hospital long before she was ready to leave. She could barely sit up.

[usonian]

20. Plus 100. "I did that."

"Advantage" is cheap for a reason. All the services they deny after you sign up.

"To Serve Man" --- it's a cookbook.

[PoindexterOglethorpe]

22. How exactly is that much different from regular Health Care plans?

I have a friend who is battling pancreatic cancer, and her health care provider keeps on denying medications she needs, including an anti-nausea patch.

The underlying problem is that almost all health care coverage of any kind, including hospitals, are for-profit. I remember several years ago people who worked for the health care companies testifying to Congress that they got bonuses for denying patient claims.

So Advantage Plans aren't the only villains out there.

I have one and I've been very happy with it so far.

[usonian]

23. The Advantage Plans don't have a monopoly on cruelty!

They learned from the experts.

Sorry about your friend and I hope that your plan serves you well.

The lobbies here are insanely powerful.

[The Jungle 1]

24. Advantage plans are a scam. RUN

[Prairie_Seagull]

26. I have often wondered if a certain level of complexity in healthcare_

Isn't intentional. As we age, I know my willingness to put up with bureaucratic bullshit has gone way down. I have file cabinets partly full of insurance shit. It almost seems reasonable at times to toss in the towel. In this thread this has been pointed out. How many people when inundated with shit just say fuck it, I would rather sit on the porch and play with my dogs. I would be willing to bet it's more than we think.

[usonian]

28. These are tough decisions, made harder by the flood of propaganda.

Look for a senior center nearby that has an advisor to go through different plans.

They can at least (and at most?) run some numbers.

I don't know of any other hopefully unbiased source of info.

The alternative to choice is limited choice. Area around my home has one hospital and two pharmacies. Period. everything else is 20 or more miles away. Thinking of moving for other reasons besides this one.

[Prairie_Seagull]

29. Solid advise, for me and my file cabinets full, I have mostly figured shit out.

What I am more speaking to is the crippling frustration I am sure some feel. I am in no way advising tossing in the towel. Just speaking to some of what I think is going on.

[usonian]

30. You might speak to friends. But that's a smallish sample of a large population.

Good luck.

[IcyPeas]

31. glad to see the Boston Globe picked up this story.

More people need to know about this. It is truly outrageous.

As if our "healthcare" industry could get any worse......

Here's a free link to the boston globe article. (it is the same as the STAT article)

https://archive.is/4daLh

[usonian]

32. Thanks! Bean Town needs to know.