This story is of interest to nursing homes as it highlights the importance of understanding how algorithmic decisions can impact patient access to care, emphasizing the need for vigilance and advocacy to ensure residents receive the appropriate and timely medical services they require
The nation’s largest health insurance company pressured its medical staff to cut off payments for seriously ill patients in lockstep with a computer algorithm’s calculations, denying rehabilitation care for older and disabled Americans as profits soared, a STAT investigation has found.
UnitedHealth Group has repeatedly said its algorithm, which predicts how long patients will need to stay in rehab, is merely a guidepost for their recoveries. But inside the company, managers delivered a much different message: that the algorithm was to be followed precisely so payment could be cut off by the date it predicted.
Internal documents show that a UnitedHealth subsidiary called NaviHealth set a target for 2023 to keep rehab stays of patients in Medicare Advantage plans within 1% of the days projected by the algorithm. Former employees said missing the target for patients under their watch meant exposing themselves to discipline, including possible termination, regardless of whether the additional days were justified under Medicare coverage rules.
(Note: link has a paywall)
Ross, C., & Herman, B. (2023, Nov 14). UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients’ rehab care. STAT. https://www.statnews.com/2023/11/14/unitedhealth-algorithm-medicare-advantage-investigation/
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
