One of the nation’s biggest health insurers, UnitedHealth Group, is reportedly under a Department of Justice criminal investigation for potential fraud within its Medicare Advantage division, the Wall Street Journal reported. This development adds another layer of scrutiny to the company’s business practices and has sent ripples of concern through the nursing home industry, which has long voiced concerns about Medicare Advantage plan practices.
While UnitedHealth stated they have not been notified of any such investigation and stand by their Medicare Advantage program’s integrity, the news has industry experts on high alert. Maureen McCarthy, president and CEO of Celtic Consulting, a firm working with post-acute care providers, emphasized the long-standing friction between providers and Medicare Advantage organizations. “For decades, Medicare Advantage organization plans have been denying care for residents and payments to the providers treating them,” she stated. McCarthy also raised concerns about the alleged use of algorithms to determine patient placement based on the likelihood of appealing denied care, suggesting this could severely restrict patient access.
This reported investigation follows a recent Senate report that highlighted how major Medicare Advantage insurers, including UnitedHealthcare, were increasingly limiting access to post-acute care to protect profits. The report found that between 2019 and 2022, these insurers denied prior authorization requests for post-acute care at significantly higher rates than for other types of care. This practice not only affects skilled nursing facility occupancy but also disrupts the crucial transition of patients from hospitals to long-term care settings. As McCarthy explained, “When they cannot transition patients to the next level because of ‘red tape’ delays, that holds the hospitals up from being able to see more patients and moving them through the healthcare process.”
The growing influence of Medicare Advantage in the healthcare system is undeniable. Currently, 51% of Medicare-eligible Americans are enrolled in these plans, and projections indicate this will rise to 59% by 2030. Against this backdrop, a criminal investigation into one of the largest players could trigger significant shifts in how these plans operate and interact with post-acute care providers. The industry will be watching closely for further developments and potential implications for resident care and reimbursement practices.