HJBR Sep/Oct 2024

MEDICARE ADVANTAGE DENIALS 10 SEP / OCT 2024 I  HEALTHCARE JOURNAL OF BATON ROUGE  Medicare’s rehab criteria without explaining why Sercovich did not need a rehab doctor, intensive team, or three hours of therapy per day. “We were in the hospital for two weeks longer than we should have been because of denials from the insurance company,” said his daughter, Sondra Sercovich. “I hope peo- ple take action, so it doesn’t take so many denials to get the proper medical care.” The OIG estimated a difference of more than $8,500 in average payments per stay caring for her child with a brain injury, said her father is now bedbound at home and dependent on family. She believes none of these complications would have happened and that her father would be walking today if Humana had permitted him to receive close medical supervision at an IRF. 5 Mandeville resident William Sercovich, also a U.S. Air Force veteran, suffered two strokes and faced multiple denials before Humana approved his request for IRF ser- vices. Both Humana denial letters repeated Since 2018, the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) has warned that Medicare Advantage (MA) plans some- times deny enrollees’ requests for essential services they need. 1,2 In response to these findings, Centers for Medicare and Med- icaid Services (CMS) finalized a 2024 rule to clarify “clinical criteria guidelines to ensure people withMAreceive access to the same medically necessary care they would receive in traditional Medicare.” 3 Unfortu- nately, providers report little improvement since the rule became effective in January. Inappropriate denials continue to cause poor outcomes for patients, hospital read- missions, and increased waste of taxpayer dollars. INPATIENT REHAB DENIALS The 2024 MA rule did not help U.S. Air Force veteran and Pearl River, Louisiana, resident George Carrigan. After complica- tions from diabetes required an amputa- tion of his leg, Humana denied his doctors’ recommendation for care at an inpatient rehabilitation facility (IRF), despite Medi- care rules listing amputation as a condition requiring such services. 4 Humana’s two denial letters said he did not need supervision from a rehab physi- cian or interdisciplinary care team, even though these clinicians would have helped to control his diabetes, monitored the healing of his wound, managed his medi- cations, and prepared him to return home independently. “The services you need can be provided safely in other settings,” wrote Humana, before sending him to a less expensive setting where his condition deteriorated. Carrigan’s daughter and family caregiver, Colleen Fickle, said her dad slipped in the nursing home’s shower and now needs wound care on the amputated limb. Poor catheter maintenance also caused him to be readmitted to the hospital with sep- sis. Fickle, who works full time while also Medicare Advantage Plan Enrollment Humana Health Benefit Plan of Louisiana, Inc. 177987 Peoples Health, Inc. 111623 Aetna Life Insurance Company 50368 Humana Insurance Company 48757 Care Improvement Plus South Central Insurance Co. 33520 Hmo Louisiana, Inc. 30084 Sierra Health And Life Insurance Company, Inc. 25531 Aetna Better Health, Inc. (LA) 12910 Wellcare Health Insurance Of Arizona, Inc. 11237 Louisiana Health Service & Indemnity Company 10166 Ochsner Health Plan, Inc. 4129 Aetna Health Inc. (LA) 2788 Community Care Health Plan of Louisiana, Inc. 2255 Wellcare Health Insurance Company of Louisiana 1972 Dignity Care Corporation 434 Franciscan Pace, Inc. 244 Anthem Insurance Companies, Inc. 201 Humana Insurance Company of New York 136 Pace Greater New Orleans 135 BCBS of Michigan Mutual Insurance Company 73 Highmark Senior Health Company 54 Health Care Service Corporation 52 TOP MEDICARE ADVANTAGE PLANS BY ENROLLMENT IN LOUISIANA Centers for Medicare & Medicaid Services (CMS). "Medicare Advantage (MA) Enrollment by State, County, and Contract - July 2024." CMS.gov. Accessed August 24, 2024. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/ mcradvpartdenroldata/monthly-ma/ma-enrollment-scc-2024-07