Two senators are demanding records from the three largest Medicare Advantage insurers over their use of AI and prior authorization to deny post-acute care to seniors.
In July 14 letters to UnitedHealthcare, Humana and CVS Health, Sens. Richard Blumenthal, D-Conn., and Josh Hawley, R-Mo., said recently published federal findings “call into question” the companies’ claims that they have reduced prior authorization burdens on members and providers amid the insurance industry’s wider commitments.
The senators are seeking records on how each insurer makes post-acute care coverage decisions, including any use of algorithms, software or AI to determine medical necessity, payment or authorization. They also asked whether it remains company policy that final denials for MA members cannot be made by AI, and requested an inventory of the predictive technologies each company uses. The insurers were given until July 28 to respond.
“This year, the federal government is projected to spend $76 billion more to cover Medicare Advantage enrollees than it would have if these beneficiaries were enrolled in Traditional Medicare,” the senators wrote. “As Humana and others continue to deny claims at record rates and pursue lucrative technologies that threaten patient wellbeing, it is incumbent upon Congress to provide oversight of this vast expenditure of taxpayer dollars.”
The letters point to two June 8 reports from the HHS Office of Inspector General that looked at June 2024 prior authorization data across 19 MA insurers. The first found that UnitedHealth, Humana and CVS denied admission requests to long-term acute care hospitals and inpatient rehabilitation facilities at rates higher than their peers. The second found that the insurers collectively denied 12% of skilled nursing facility requests, with nearly all appealed denials later overturned. Both reports flagged the notable role of naviHealth, a utilization management vendor under UnitedHealth’s Optum.
UnitedHealth’s alleged use of AI in coverage decisions has also been the subject of an ongoing class action in Minnesota brought by the families of deceased Medicare Advantage members, who claim an AI product from naviHealth drove post-acute care denials. In March, a federal magistrate judge ordered UnitedHealth to produce a wide range of documents involving the tool and the company’s policies and procedures surrounding post-acute care coverage. Optum has previously said coverage decisions are made by physicians following CMS guidance, not AI.
The latest Senate inquiry builds on an October 2024 subcommittee report that reviewed more than 280,000 pages of internal documents and concluded the three insurers denied prior authorization for post-acute care at far higher rates than for other types of care. That report found denials rose as the companies adopted automated review processes.
In a follow-up letter last October, Sen. Blumenthal pressed the insurers to detail how their AI tools are used and any policies that might limit the technology’s influence on human clinicians.
In January, Sens. Elizabeth Warren, D-Mass., and Ron Wyden, D-Ore., expanded a separate probe into UnitedHealth’s nursing home programs, citing whistleblower documents and allegations that Optum delayed or denied hospital transfers for residents. The expansion followed December reporting by The Guardian that detailed three cases in which nursing home residents allegedly died after Optum delayed or denied transfers, while the original probe followed a May report accusing the company of incentivizing nursing homes to avoid transfers. UnitedHealth has denied the allegations and sued the news outlet for defamation last year, calling its reporting “unquestionably defamatory.”
A spokesperson for CVS told Becker’s the company has “received the letter and will respond to the Senators.” Humana declined to comment.
“The OIG reports take a narrow and incomplete view of a review process that helps seniors receive timely, high-quality care, in the most appropriate setting. UnitedHealthcare approves the vast majority of post-acute care requests, most almost instantly,” a spokesperson for UnitedHealthcare said. “When decisions are overturned on appeal, it reflects a process that allows for continued clinical evaluation, particularly when new or more complete information becomes available, which is common in complex cases. Across all settings, our approach is grounded in evidence-based clinical criteria aligned to industry and CMS standards and safety principles, ensuring members receive care in the most appropriate setting for their clinical needs.”
Insurance trade group AHIP has also pushed back on the OIG reports, saying they omit context such as missing documentation and administrative reasons behind denials, and ignore research on cost and quality variation in post-acute care.
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