Artificial Intelligence in Medicare Advantage Plans Impedes Access to Care

Yves here. Even though we ran a post recently on the horrorshow of Medicare Advantage using AI to implement what amounts to reductions in coverage below contractually stipulated levels, this practice is so egregious that it needs to be called out until something is done to stop it.

The case that is the centerpiece of a new report, below, is particularly disturbing because the adjudication process (much like arbitration of securities and credit card cases) looks to be cooked to find against patients.

By run75441. Originally published at Angry Bear

If you have read Medicare Advantage uses Algorithms to block care for Seniors, Angry Bear, (STAT Investigation, Casey Ross and Bob Herman) you might think this is a relatively new phenomena in healthcare. At the bottom of the post you will find a link to another commentary. Why did I put another commentary site there as written by different authors?

Number one, so I would not forget it. Number two, to make a point of showing the use of algorithms in overall and Medicare healthcare insurance is not new. How long has it been in use, I am not sure. The commentary by St, John and Krupa is almost one year old and very relevant.

This is another case study of how Medicare Advantage is defining treatment options for patients. The pattern is to measure a new patient based upon what has occurred with other patients. A1is followed religiously by Advantage plans is failing to identify the uniqueness of each patient. Some difference between patients may not be picked up by A1.

When Artificial Intelligence in Medicare Advantage Impedes Access to Care: A Case Study, Center for Medicare Advocacy, C. St. John and E. Krupa

The use of artificial intelligence (AI) in healthcare is capturing headlines as a potential tool to streamline operations and predict patient needs for favorable health outcomes, among other things.[1] The Center for Medicare Advocacy has increasingly become aware of how AI-powered decision-making tools may be used by Medicare Advantage (MA) plans to make coverage decisions. Those decisions may be more restrictive than Medicare coverage guidelines, potentially leading to premature terminations of coverage or continuation of care for beneficiaries.[2]

The Center recently published a report, The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations, outlining areas of growing concerns. Issues around the use of AI have also been highlighted by the Commonwealth Fund as part of a series of blog posts focusing on different aspects of the MA program.[3] A recent blog post noted,

“A related concern is that plans are using proprietary, algorithm-driven systems to make decisions (including those requiring prior authorization) about approving coverage for services.”[4]

The issues around prior authorization and persistent denials of coverage potentially have devastating impacts on patients. The Center for Medicare Advocacy is hearing alarming cases of Medicare beneficiaries suffering from impacts of AI decision-making tools despite the fact that Medicare is adamant that no claim should be based on a screening tool alone.[5] Furthermore, Medicare requires an individualized assessment of each beneficiary’s qualification for coverage in certain care settings.[6] The AI tools, however, provide recommendations based on previous patient experiences.

One beneficiary in Connecticut, Ms. M, was hospitalized after she underwent a hip replacement. The 80-year-old was transferred to a skilled nursing facility (SNF) for short-term rehab. Ms. M’s UnitedHealthcare Medicare Advantage plan touts that it offers coverage of unlimited days in a SNF.

Ms. M’s goal in the nursing home was to reach a level of independence that would allow her to return home where she lived on her own prior to the surgery.  Her recovery in the SNF was being hindered due to various complications such as a nerve injury and becoming infected with COVID-19. Nevertheless, Ms. M was still able to make progress consistent with the goals set out in the physical and occupational therapy evaluations.  According to Paula Haney, the Director of Rehabilitation at the SNF, Ms. M. was still benefiting from her skilled therapy regimen and, therefore, continued to meet Medicare coverage criteria.

Despite this fact, Ms. M has been forced to battle UnitedHealthcare for continued coverage of her three-month stay at the facility. While trying to regain mobility after her hip operation, Ms. M filed ten appeals on UnitedHealthcare’s repeated decisions to terminate her coverage.

Paula Haney explained to the Center these frequent denials have increased for her patients,

“I have never experienced the number of denials that we have received. The frustrating part is that we have overturned so many of those denials and yet they keep coming.”

Ms. M reached out to the Center after filing the ten successful appeals on her own. The Center contacted both United Healthcare and their subsidiary naviHealth. naviHealth is a post-acute case management company which determines when to terminate coverage and to find out more about how these decisions were being made. After finally agreeing to meet with the Center and Haney, naviHealth’s clinical representative continued to offer multiple explanations as to why coverage should be terminated. Included in the explanations were: Ms. M’s goal of returning home being unrealistic and the therapy she was receiving could be provided by someone who was not skilled.

According to Haney, naviHealth provides similar explanations for their other denials.

“Basically, what we’re hearing is either the patient is not making adequate progress, or the patient has reached a level that should not require skilled services. There isn’t a whole bunch of clarification.”

Haney recounted to the Center how the repeated denials of coverage impacted patients.

“They’re dealing with trying to get better. And it’s this emotional roller coaster every five to seven days.”

Ms. M doesn’t have the financial means to privately pay for continued short-term rehab and the weekly denials took a serious emotional toll.

“She would come down here and be a wreck. She’d be weeping. Just so worried. ‘What’s going to happen? Are they going to take my house? What do I do now?’”

Despite her Medicare Advantage plan stating it covered unlimited days in a SNF, Ms. M received less than a month of coverage before the barrage of terminating notices began. Unfortunately, Ms. M’s case is not unique, but her fighting spirit is. According to a 2018 Office of the Inspector General report, beneficiaries and providers appealed only one percent of the Medicare Advantage denials between 2014 and 2016.[7]

“We’ve had a couple of people who have gone home and ended up back in the hospital. And we’ve seen them again,” according to Haney.

“We’re happy to see them if they need us, but we really would rather have it if they had gotten a little bit stronger, maybe they would have been able to avoid that rehospitalization.”

The Center continues to investigate AI-powered decision coverage issues and will provide updates as we learn more.

Unfortunate update: Kepro, the independent adjudicator of Ms. M’s appeals, has finally upheld naviHealth’s Notice of Medicare Non-Coverage despite her continuing to receive therapy each weekday.


[1] Landau, J. The pluses and minuses of AI in Healthcare. Fast Company. (Feb. 28, 2022).

[2] Saxena, L. Center for Medicare Advocacy Special Report: The Role of AI-powered Decision-Making Technology in Medicare Coverage Determinations. Center for Medicare Advocacy. (Jan. 19, 2020).

[3] CMA. Commonwealth Fund Blog Series About Medicare Advantage. (Apr. 7, 2022).

[4] Hostetter, M., & Klein, S. Taking Stock of Medicare Advantage: Benefit Design. Commonwealth Fund. (Mar. 31, 2022).

[5] Saxena, L. Center for Medicare Advocacy Special Report: The Role of AI-powered Decision-Making Technology in Medicare Coverage Determinations. Center for Medicare Advocacy. (Jan. 19, 2020).

[6] CMS. Frequently Asked Questions (FAQs) Regarding Jimmo Settlement Agreement. (Updated Dec. 1, 2021)

[7] OIG. Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials. (OEI-09-16-00410) 09-25-2018.

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  1. Boomheist

    There is an established formal appeal process to dispute Medicare charges, or refusal of coverage, with Original Medicare and also with MA plans. The process takes attention, time, and focus. I think there is data out there that shows that a huge percentage of appeals properly filed are accepted, in the end (though not, unfortunately, in the article above) but “…the end” can take days and weeks, several steps, and unbelievable anxiety on the part of the affected patient. If you have a champion for your appeal, someone to do the filing, follow up, make sure all is in order, someone not ill themselves, the process is easier, but who has such a champion? Point being, a cynic – and I am one – might argue that this is not a flaw in the system but the design – make the process so tedious and scary and difficult that a large majority of patients give up before reaching resolution, which means, effectively, ceding the false charge to the company. Using AI to automate this, make it effectively costless to the company, is, in a sick sort of way, nearly brilliant.

    Advantage Plans, as opposed to Original Medicare, promise one-stop shopping for your needs, offer additional insurances beyond Original Medicare’s A, B and D, offer policies with zero premium (except for the Part B 165 a month) AND claim you are protected from disaster due to the Maximum Out of Pocket guarantee. However, that maximum is generally in the range of $ 5500 to $ 7500 a year, so if you get sick or a Black Swan hits you or you have a very high annual medical maintenance cost, in the end the MA plan is much more costly than Original Medicare with a Medigap. Not to mention that with an MA plan you are restricted to the doctors in the network, the plans can change year to year, or even go away, and as the article here states, improper charges can bury you. What most people don’t know is every MA plan is being given a direct cash contribution from Uncle Sam in the range of $ 800 to $ 1000 a month, which allows them to offer no premium plans, pay for all those Joe Namath ads, and steadily eat away at the percentage of people staying with Original Medicare.

    1. Grateful Dude

      I filed a Medicare claim for acupuncture. It was denied. I called Medicare a couple of times and was told that it should have been covered – the Medicare website says that acupuncture – “” – is covered for lower back pain if the practitioner is educated and licensed. So I appealed. I believe sciatica qualifies as lower back pain …. This time I was denied because practitioners cannot register with Medicare so they cannot file claims, using a rule that went into effect after my treatment and my initial claim. I appealed again and was again denied: I had filed the claim and the Dr met the eligibility reqs.

      The denials were all made by some corporation, Noridia, for reasons they just made up. My only option left was arbitration, and I let it go; I wasn’t well and missed the deadline to schedule it. I would’ve loved to take Medicare to small claims court.

  2. Arizona Slim

    Slim here. Once again, here’s a big dose of gratitude for NC. You kept me out of the clutches of those so-called Advantage plans.

    Thank you!

  3. ambrit

    There in stark black and white is the difference between a Public public health system and a Private public health system.
    By definition, anything “private” is designed to make money. The easiest way for a private medical system to keep more of the money it takes in is to deny care. The algorithms can be designed for that purpose.
    These so called AI systems are literal “soulless bureaucrats.” Funny to see, but these AI systems make the urbanely mythical ‘Government workers’ look good.
    On a related note; I do see an opening for a particularly inventive CT theorizing that these AIs are designed to increase the stress level in the most vulnerable populations. The resulting increase in early deaths is just a lagniappe for the Jackpot Steering Committee.
    Stay safe. Stay healthy.

  4. Watt4Bob

    Keeping in mind the fact that tech innovations are always sold before they are ready for prime time, I think we can expect a wave of sketchy implementations of AI, many of which will be just as bad, if not vastly worse than what is probably a default instruction* to deny claims.

    *There are, or have been reports from health Insurance claim agents that their instructions are to deny claims on the first pass.

    Anyway, AI is going to implemented in all sorts of ways that will further immiserate the masses.

    For instance, AI will be aggressively sold to all the greedy psychos as a way to increase their harvests of the low hanging fruit waiting in the stolen personal data they possess, the fruit of hackers selling on the dark web.

    And automated data-mining via AI is bound to magnify the already negative impacts we experience on the web because of the total surveillance of our web related activity.

    And of course we can’t forget the Sci-Fi stuff which isn’t necessarily ‘fiction‘.

  5. Grayce

    Side-by-side with MA plans is the employer-sponsored retiree health plan that is “self-insured.” That means the employing corporation is the de facto insurer, with someone else providing “administrative services only” or ASO. When a part of the premium is paid by the retired employee, the incentive is in place to spend as little of it as possible.
    So, the ASO is often an insurance company that already owns the algorithms to quibble, and the participant loses a few intervals while employer and ASO bandy about the place to even send an appeal of a claim. The ASO has the first round of delay-and-denial steps, then an enterprising retiree may send the materials to the plan administrator under the idea that the employer is the insurer who has an ERISA duty to monitor third parties. The employer extends the second round by responding as if there are technical errors blocking actual claims and appeals materials.

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