Photo by Levi Meir Clancy
Photo by Levi Meir Clancy
Medicare Advantage insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient's treatment.
Sen. Elizabeth Warren joined healthcare campaigner Ady Barkan and others on Monday in sounding alarm over a recent investigation showing that Medicare Advantage insurers are using unregulated artificial intelligence systems to determine when to end payments for patients’ treatments, a practice that has prematurely terminated coverage for vulnerable seniors.
STAT reported earlier this month that while “health insurance companies have rejected medical claims for as long as they’ve been around,” AI is “driving their denials to new heights in Medicare Advantage,” a privately run program funded by the federal government.
“Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment,” the outlet found. “The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.”
“Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it,” STAT continued. “If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.”
Barkan, co-executive director of Be a Hero and an ALS patient who is acutely aware of the injustices at the heart of the United States’ for-profit healthcare system, tweeted Monday that STAT’s reporting is “outrageous and terrifying” and circulated a petition imploring the Biden administration to crack down on the Medicare Advantage industry’s use of AI.
“This barbaric practice must end,” the petition states. “We’re calling on President Biden and the [Centers for Medicare and Medicaid Services] to stop this practice immediately.”
Warren (D-Mass.), who blasted the huge profits of top Medicare Advantage insurers last week, echoed Barkan in a tweet of her own.
“Medicare Advantage insurers make patients look as sick as possible to overcharge taxpayers billions,” Warren wrote, referring to a common industry practice known as upcoding.
“At the same time, they deny seniors and people with disabilities care—with the help of AI algorithms,” the senator continued. “We must crack down on these abuses. No more #DeathByAI.”
An analysis published last year in the Journal of Medical Internet Research found that “despite the plethora of claims for the benefits of AI in enhancing clinical outcomes, there is a paucity of robust evidence.”
But that lack of evidence hasn’t stopped hugely profitable private healthcare companies from increasingly using AI tools to “help make life-altering decisions with little independent oversight,” STAT determined after reviewing secret corporate documents and hundreds of pages of federal records and court filings.
“Over the last decade, a new industry has formed around these plans to predict how many hours of therapy patients will need, which types of doctors they might see, and exactly when they will be able to leave a hospital or nursing home,” STAT reported. “The predictions have become so integral to Medicare Advantage that insurers themselves have started acquiring the makers of the most widely used tools.”
“Elevance, Cigna, and CVS Health, which owns insurance giant Aetna, have all purchased these capabilities in recent years,” the outlet continued. “One of the biggest and most controversial companies behind these models, NaviHealth, is now owned by UnitedHealth Group.”
In 2020, a UnitedHealthcare algorithm determined that 89-year-old Dolores Millam—who broke her leg in a fall that year—would only need to stay in a nursing home for 15 days following surgery, STAT reported.
After the 15 days were up, Millam “received notice that payment for her care had been terminated.” Millam’s daughter, Holly Hennessy, told STAT that “she couldn’t fathom UnitedHealthcare’s conclusion that her mother unable to move or even go to the bathroom on her own—no longer met Medicare coverage requirements.”
“Hennessy said she had no choice but to keep her mother in the nursing home, Evansville Manor, and hope the payment denial would get overturned,” STAT reported. “By then, the bills were quickly piling up.”
UnitedHealthcare rejected Millam and Hennessy’s appeal, forcing them to pursue relief in federal court—an arduous process.
A federal judge finally ruled months later that UnitedHealthcare improperly denied Millam that she was entitled to full coverage.
The total bill for her nursing home stay was $40,000, according to STAT.
Barkan warned Monday that “insurance behemoths using AI to squeeze every cent out of us.” Just seven healthcare companies control more than 70% of the Medicare Advantage market.
“President Biden has the power to stop this,” Barkan wrote of Medicare Advantage plans’ use of AI. “We’re meeting with White House staff this week to discuss this outrage.”
Republished with permission from Common Dreams, by Jake Johnson
Common Dreams has been providing breaking news & views for the progressive community since 1997. They are independent, non-profit, advertising-free and 100% reader supported.
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