Tag: HHS Office of Inspector General

Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

By Susan Jaffe, KFF Health News | October 5, 2023

This article also ran in The Washington Post.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from h when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. NaviHealth’s proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long. 

 

…Next year, the Centers for Medicare & Medicaid Services will begin restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.[Continued on Kaiser Health News and The Washington Post.]…

A Covid Test Medicare Scam May Be a Trial Run for Further Fraud

By Susan Jaffe, KHN  | May 18, 2023 | This story also ran on  

Medicare coverage for at-home covid-19 tests ended last week, but the scams spawned by the temporary pandemic benefit could have lingering consequences for seniors.

Medicare advocates around the country who track fraud noticed an eleventh-hour rise in complaints from beneficiaries who received tests — sometimes by the dozen — that they never requested. It’s a signal that someone may have been using, and could continue to use, seniors’ Medicare information to improperly bill the federal government. …One beneficiary in Indiana suspected something was amiss after receiving 32 unrequested tests over a 10-day period. [Continued on Kaiser Health News, NPR, Yahoo News, and St. Louis Post-Dispatch]…

Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage

By Susan Jaffe  | Kaiser Health News | August 12, 2019 | This KHN story also ran on Salon and Next Avenue  

Medicare paid for Betty Gordon’s knee replacement surgery in March, but the 72-year-old former high school teacher needed a nursing home stay and care at home to recover.

Yet Medicare wouldn’t pay for that. So Gordon is stuck with a $7,000 bill she can’t afford — and, as if that were not bad enough, she can’t appeal.

The reasons Medicare won’t pay have frustrated the Rhode Island woman and many others trapped in the maze of regulations surrounding something called “observation care.”

Patients, like Gordon, receive observation care in the hospital when their doctors think they are too sick to go home but not sick enough to be admitted. They stay overnight or longer, usually in regular hospital rooms, getting some of the same services and treatment (often for the same problems) as an admitted patient….

(Photo courtesy of Betty Gordon)

But observation care is considered an outpatient service under Medicare rules, like a doctor’s appointment or a lab test. Observation patients may have to pay a larger share of the hospital bill than if they were officially admitted to the hospital.Medicare’s nursing home benefit is available only to those admitted to the hospital for three consecutive days. Gordon spent three days in the hospital after her surgery, but because she was getting observation care, that time didn’t count.

There’s another twist: Patients might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.

Monday, a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people.  [Continued at Kaiser Health News, Next Avenue or Salon]

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