Constitution State News

“The reappearance of Melanoma in 2022 pulled a rug out from under my husband and my family. Then came the added trauma which piled on steadily of having to fight to keep him receiving the care he needed,” said Connecticut resident Gloria Bent.

[WASHINGTON, DC] – U.S. Senator Richard Blumenthal (D-CT), Chair of the U.S. Senate Permanent Subcommittee on Investigations (PSI), convened the Subcommittee’s first hearing of the Congress on how some seniors enrolled in Medicare Advantage plans face barriers accessing necessary care. Gloria Bent, a resident of Connecticut, shared testimony about her firsthand experience facing those barriers to care after her husband’s Hodgkin’s Lymphoma and Melanoma returned.

While an acute care hospital in Wallingford had a bed and accepted Gloria’s late husband, Gary, a representative from naviHealth, a company owned by UnitedHealthcare, denied the request and stated Gary, “wouldn’t be able to withstand the intense therapy schedule,” even though it was prescribed for him by his surgeons and therapists. Later, when Gary was admitted to another facility with a lower level of acuity, his Medicare Advantage insurer notified them that they would soon discharge Gary. Gloria was told a representative from by naviHealth, “If I lived in a home that was not handicap accessible, which ours wasn’t, then I needed to move.”

After they received their first denial of coverage, well ahead of when Gary’s doctors said he should be discharged, Gloria said  that she was told by those caring for her husband to, “expect regular reviews of his health notes, that I could expect a series of notices of denial of Medicare payment accompanied by a discharge date.” According to Gloria, in the seven weeks that Gary was at the skilled nursing facility, he received three denials of coverage, with the last two coming four days apart. 

After hearing Gloria’s story, Blumenthal said, “It is a system that is failing people like yourself and your husband and your entire family because, as you put it so well, the trauma hit not just your husband, but your entire family.”

Blumenthal described how decisions made by Medicare Advantage insurers are reportedly driven by algorithms and often lead to denied requests for care, saying, “naviHealth actually relies on algorithms, not on a clinician’s review, not on a physician or a surgeon examining the medical records of your husband, but on an algorithm. And in fact, a lot of money has been made as a result of selling naviHealth and its system from one company to another.”

Blumenthal noted that one study showed that out of 35 million Medicare Advantage requests in 2021, 2 million were denied completely, but out of the small number of denials that were appealed, 80% were granted, showing, “the vast majority of appeals were found meritorious, but only a small percentage had the wherewithal, the patience, the time, the resources, or the simple fortitude in the face of this battlefield, as Ms. Bent has described it, to actually take it to an appeal.”

Jeannie Fugelsten Biniek, the Associate Director of Medicare Policy at Kaiser Family Foundation, echoed these findings, stating, “We looked across insurers and this was consistent across nearly every insurance firm that offers Medicare Advantage plans. They overturned the vast majority of their initial decisions upon appeal.”

Christine Huberty of the Greater Wisconsin Agency on Aging Resources emphasized the burden of the appeals process, saying, “You have people who are vulnerable, sick, and ill trying to recover and get back home. They are getting appeals thrown at them, not knowing what they’re signing or what is being asked of them…Even if you are successful in an appeal, you can expect another denial in a matter of days and that review will continue every three days.”

“This should not be happening to families and patients. It’s cruel,” said Gloria.

Video of Blumenthal’s questions can be found here. Video of Bent’s opening remarks can be found here.

Yesterday, PSI sent bipartisan letters to the three largest insurers in the Medicare Advantage program – UnitedHealthcare, Humana, and CVS Health – seeking additional information to determine the full extent of coverage delays and denials.

PSI is the Homeland Security and Governmental Affairs Committee’s chief investigative subcommittee and is tasked with broad authority to investigate crimes, fraud and violations of consumer protections, and threats to national security. PSI has previously conducted investigations into a wide range of criminal activity, corporate malfeasance, and government waste, fraud and abuse. More information on the history of PSI is available here.

Original source can be found here