Medicare Advantage Denials & CMS Therapy Double-Talk

Medicare Advantage: The Denial Machine Keeps Humming

Nearly 30% of nursing homes report getting hit with Medicare Advantage denials every single day according to AHCA's latest survey of 363 providers. That's not weekly or monthly - that's daily rejections of what doctors say patients actually need. Another 37% get denied weekly, and 67% have had MA plans yank coverage early against medical advice. The best part? Most denials get overturned on appeal which means the insurance companies know they're wrong but make you fight for it anyway. It's like having a bouncer at a restaurant who randomly tells customers they can't order food, knowing the manager will override him later.

The culprit is AI and algorithms that major MA companies like UnitedHealth and Humana use to automatically deny post-acute care because nothing says quality healthcare like letting computers overrule doctors.

Senate investigators found MA plans deny post-acute care requests at higher rates than other types of care and both UnitedHealth and Humana are currently getting sued over their AI denial systems. Forty health insurance providers recently promised to "overhaul" their prior authorization processes after the bad publicity, but operators are still dealing with the daily grind of fighting robots for coverage their patients already paid for. The insurance industry's solution to rising healthcare costs? Make it so annoying to get care that people give up.

CMS Therapy Double-Talk: "We Love Prevention!"

CMS just released their Physician Fee Schedule proposal that's supposedly all about "chronic disease management" and "nutrition measures" - basically admitting that keeping people healthy is cheaper than fixing them after they break. Sounds great, right? Except they're simultaneously cutting reimbursement for the therapy codes that actually prevent falls and keep seniors mobile.

It's like a restaurant promoting healthy eating while removing salads from the menu. ADVION's Cynthia Morton points out the contradiction: "Low cost therapy services go a long way to help a senior with their gait so that they are at a much lower risk for a fall" - but apparently CMS thinks prevention works better in PowerPoint presentations than in actual physical therapy sessions.