Senators press healthcare insurers over denials Senators press UnitedHealthcare and other Medicare Advantage giants over payment denials

Federal lawmakers are turning up the pressure on UnitedHealthcare and two rival Medicare Advantage insurers over their use of artificial intelligence and their prior authorization rules for post-hospital rehab care.

U.S. Sen. Richard Blumenthal, a Democrat from Connecticut, and Sen. Josh Hawley, a Republican from Missouri, sent letters this past week to the CEOs at these insurance companies, demanding more information about their process for denying or approving these coverage requests.

The requests come amid intensifying scrutiny of the nation's largest Medicare Advantage insurers.

Last month, a new report from the Office of Inspector General at the U.S. Department of Health and Human Services found UnitedHealthcare, Humana and CVS Health denied Medicare patients' requests for post-hospital care at much higher rates - 51% to 80% of the time - than other insurers.

And a relevant 2023 lawsuit filed in Minnesota remains unresolved. It alleges Eden Prairie-based UnitedHealthcare wrongly used AI and other business practices to boost profits at the expense of patient access to care.

Medicare Advantage plans are privatized versions of the government's Medicare program offered through health insurance companies.

"Because of an absence of comprehensive reporting requirements, Medicare Advantage insurers are able to hide the full extent of denials of care resulting from their abuse of prior authorization," Blumenthal and Hawley wrote in their letter to Tim Noel, the UnitedHealthcare CEO.

The senators are members of a subcommittee that issued an October 2024 report finding the same three companies were denying prior authorization requests for post-acute care at three times the rate of requests for other types of care. Prior authorization rules allow insurers to decline to pay for care unless approved in advance.

The new federal reports "suggest that little has changed, and call into question claims your company has made since the release of the Subcommittee's report that it is reining in prior authorization," the senators wrote.

"As UnitedHealthcare 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 senators wrote.

UnitedHealthcare says the watchdog reports take "a narrow and incomplete view" of the company's review process, since the insurer approves the vast majority of post-acute care requests. The company also stressed: "We do not use AI for clinical denials."

One of the June reports highlighted practices at a company called naviHealth that's operated by UnitedHealthcare's corporate parent, Eden Prairie-based UnitedHealth Group.

naviHealth initially rejected a high rate of requests for admission to skilled nursing facilities, only to later overturn almost all decisions when patients appealed, the watchdog agency found. That indicates initial denials blocked medically necessary care, OIG said, and raised concerns about denials that were not appealed.

In a statement, the insurer said such overturns reflect a process that allows for continued clinical evaluation, especially when new or more complete information becomes available.

"Across all settings, our approach is grounded in evidence-based clinical criteria aligned to industry and (federal) standards and safety principles, ensuring members receive care in the most appropriate setting for their clinical needs," the company said in a statement.

Prior authorization rules set by private health insurers have been at the heart of growing tensions between insurance companies and health care providers in recent years.

Fairview Health Services in Minneapolis referenced prior authorization delays in June, when the health system announced it would not schedule appointments next year for seniors with UnitedHealthcare Medicare Advantage coverage.

One of the watchdog reports published last month looked at prior authorization denials for care at post-hospitalization rehab facilities, where patients can spend weeks receiving medical, therapeutic and rehabilitation care in order to return home. In 2023, Medicare's average cost for a stay ranged from $16,000 to $49,000.

Insurers say their scrutiny of patients' requests is warranted given those prices and the large variation in cost and quality among care providers who also have profit motives.

In their letter to UnitedHealthcare, the senators cited federal findings that the insurer denied 66% percent of admission requests to inpatient rehabilitation facilities, while 16 smaller insurers covering Medicare Advantage beneficiaries denied an average of 41% of these requests.

Patients and families filed suit in the U.S. District Court of Minnesota in 2023, alleging UnitedHealthcare used naviHealth's artificial intelligence tool to cut off coverage of rehabilitation care after hospitalization. Plaintiffs contend they still needed the care, so the denials forced difficult decisions on whether to pay out of pocket or forgo the remainder of their prescribed care.

In March, U.S. Magistrate Judge Shannon Elkins ruled plaintiffs' ability to obtain documents in the case should go back to 2017, in part because the U.S. Senate subcommittee's report indicated UnitedHealthcare's denial rate more than doubled after the company began using naviHealth and a related product in 2019.

A trial in the case is scheduled for December 2027.