Traditional Medicare can’t cut nursing-home stays short, but Medicare Advantage plans can, and they are doing just that

By Al Cross Published October 10, 2022 FEATURED, HEALTH BUSINESS, HEALTH POLICY

“Health care providers, nursing-home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home,” Susan Jaffe reports for Kaiser Health News.

Half of the nearly 65 million people in Medicare have Medicare Advantage, an umbrella term for private health plans that are alternatives to the traditional government program, They must cover, at a minimum, the same benefits as traditional Medicare, including up to 100 days of skilled nursing care each year, Jaffe reports. But the Advantage plans “have leeway 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,” Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries, told Jaffe. “In Medicare Advantage, the plan decides.”

Jaffe offers several examples of nursing-home patients who were told by their Medicare Advantage insurer that they would have to go home before their medical team deemed them well enough to do so.

One of those patients was Paula Christopherson, 97, who was in a skilled nursing facility in St. Paul, Minn., recuperating from a fall. Daughter Amy Loomis told Jaffe that the facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home: “This seems unethical.”

Christopherson ended up staying and appealed UnitedHealthcare‘s decision to deny an additional five days of care in the nursing home. Upon returning home, she got a bill for nearly $2,500 from the facility and that it took repeated appeals before United Healthcare reversed its decision, Jaffe reports.

Jaffe explains how Advantage plans work: “The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits,” according to an April analysis by the Department of Health and Human Services’ 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.”

She adds that HHS’s “Centers for Medicare & Medicaid Services recently signaled its interest in cracking down on unwarranted denials of members’ coverage. In August, it asked for public feedback on how to prevent Advantage plans from limiting “access to medically necessary care.””

Experts told Jaffe that nursing homes and Medicare Advantage plans have “reverse incentives” when it comes to making a profit; nursing homes make more when a patient has an extended stay, while Medicare Advantage plans are incentivized to deny or restrict coverage to increase their profits.

Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners, told Kaiser Health News that the problem has become “more widespread and more frequent.” He added, “It’s not just one plan. It’s pretty much all of them.”

Kumar told Jaffe that with the spike in Medicare Advantage enrollment, disagreements between insurers and nursing home medical teams have increased.

“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’s criteria for medically necessary care and involve a review of members’ medical records and clinical conditions. If members disagree, she said, they can appeal,” Jaffe reports.

Jaffe reports that 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.

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.