After 11 days in a St. Paul, Minnesota, skilled nursing facility recovering from a fall, Paula Christopherson, 97, was told by her insurer that she had to go home.
But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.
“It seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, operated by UnitedHealthcare, ended coverage for her mother’s nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.
Health care providers, nursing home representatives and advocates for residents say Medicare Advantage plans are increasingly terminating members’ coverage for nursing home and rehabilitation services before patients are well enough to go home.
About half of the 65 million people with Medicare are enrolled in private health plans called Medicare Advantage, which are alternatives to traditional government programs. Plans must cover — at a minimum — the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care per year.
But individual planning has scope when deciding how much nursing home care a patient needs.
“In traditional Medicare, the medical professionals at the facility decide when someone is safe to go home,” said Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. “In Medicare Advantage, the plan decides.”
“People are going to nursing homes, and then getting denied very quickly, and then being asked to appeal, which adds to their stress when they’re already healthy,” said Mairead Painter, a vice president of the National Association of State Long-Term Care Ombudsman Program, which operates the Connecticut office. Trying to be.”
The federal government pays a monthly amount for each person enrolled in a Medicare Advantage plan, regardless of how much care that person needs. That “increases potential incentives for insurers to deny payment in an effort to increase access to services and profits,” according to an April analysis by the Department of Health and Human Services’ inspector general. The investigators found that nursing home coverage was among the most frequently denied services by private plans and was often covered by traditional Medicare.
The federal Centers for Medicare and Medicaid Services recently signaled its interest in cracking down on unreasonable denials of coverage to members. In August, it sought public feedback on how to prevent Advantage plans from limiting “access to medically necessary care.”
The limits on nursing home coverage come after decades of efforts by insurers to reduce hospitalizations, initiatives designed to help lower costs and reduce the risk of infection.
Charlene Harrington, a professor emerita at the University of California-San Francisco School of Nursing and an expert on nursing home reimbursement and regulation, says nursing homes have an incentive to extend residents’ stays. “Length of stay and occupancy are the main predictors of profitability, so they want to keep people as long as possible,” he said. Many facilities still have empty beds, a lingering effect of the Covid-19 pandemic.
When to leave a nursing home “is a complicated decision because you have two groups that have opposite incentives,” he said. “People are probably better off at home,” he said, if they are healthy enough and have family members or other sources of support and safe housing. “Residents should have a say in this.”
Jill Sumner, a vice president of the American Health Care Association, which represents nursing homes, said her group has “significant concerns” about large Advantage plans ending coverage. “Health plans can determine how long someone is in a nursing home without typically looking at the person,” he said.
The problem “has become more widespread and more frequent,” said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “It’s not just a plan,” he said. “That’s about all of them.”
Medicare Advantage enrollment has increased in recent years, Kumar said, increasing friction between insurers and nursing home medical teams. In addition, he said, insurers have hired companies like Tennessee-based NaviHealth, which use data about other patients to help predict how much care a person needs in a skilled nursing facility based on his or her health status. Those calculations may conflict with the recommendations of medical teams, he said.
UnitedHealthcare, the largest provider of Medicare Advantage plans, bought NavyHealth in 2020.
Nursing homes are feeling the impact, Sumner said. “Since the advent of these companies, we’ve seen shorter dwell times,” he said.
In a recent news release, naviHealth said its “predictive technology” can help patients “enjoy more days at home and significantly reduce costs to healthcare providers and health plans.”
UnitedHealthcare spokeswoman Heather Soule would not explain why the company limited coverage for members mentioned in this article. But, in a statement, he said such decisions are based on Medicare’s medically necessary care standards and involve a review of members’ medical records and clinical conditions. If members disagree, he said, they can appeal.
When a patient no longer meets a skilled nursing facility’s coverage criteria, “it doesn’t mean the member no longer needs care,” Soule said. “That’s why our care coordinators actively engage with members, caregivers and providers to guide them through an individualized care plan focused on members’ unique needs.”
She noted that many Advantage plan members prefer to receive care at home. But some members and their advocates say that option isn’t always practical or safe.
Patricia Maynard, 80, a retired Connecticut school cafeteria worker, was in a nursing home recovering from a hip replacement in December when her UnitedHealthcare Medicare Advantage plan notified her it was ending coverage. His doctors disagreed with this decision.
“If I had, I would have to pay,” Maynard said. “Or I can go home and not worry about a bill.” Without insurance, the average daily cost of a semi-private room in her nursing home was $415, according to a 2020 state survey of facility charges. But even going home was impractical: “I couldn’t walk because of the pain,” she said.
Maynard appealed and the company reversed its decision. But a few days later, he received another notice that the plan had again decided to stop paying over the objections of his medical team.
The cycle continues 10 more times, Kripa said.
In a statement, CMS spokeswoman Beth Link said Maynard’s repeated appeals are part of the normal Medicare Advantage appeals process.
When a request to an Advantage plan is unsuccessful, members can appeal to an independent “quality improvement organization,” or QIO, which handles Medicare complaints, Link said. “If an enrollee receives a favorable decision from the QIO, the plan or facility must continue to pay for the nursing home stay until the member or patient decides it is no longer necessary,” he explained. Residents who disagree can file another appeal.
CMS could not provide data on how many beneficiaries had their nursing home care terminated by their Advantage plans or how many were successful in reversing the decision.
To make fighting denials easier, the Center for Medicare Advocacy has developed a form to help Medicare Advantage members file complaints with their plans.
When UnitedHealthcare decided it would not pay for an additional five days at the nursing home for Christopherson, he stayed at the facility and applied. When he returned to his apartment, the facility billed him about $2,500 for that time.
After Christopherson repeatedly appealed, UnitedHealthcare reversed its decision and paid for his entire stay.
Loomis said her family remains “honored” by her mother’s ordeal.
“How can an insurance company deny coverage recommended by its medical care team?” Loomis asked. “They’re experts, and they deal with people like my mom every day.”
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