RISE summarizes recent regulatory-related headlines.
HUMANA LATEST INSURER TO FACE LAWSUIT OVER USE OF AI TO DENY MA CLAIMS
Weeks after families sued United Health for using artificial intelligence (AI) programs to deny post-acute care to Medicare Advantage patients, Humana is facing similar legal troubles. Axios reports that the class action suit was filed in federal court in Kentucky and claims Humana used an algorithm to wrongly deny care to elderly patients. The plaintiffs include an 86-year-old woman from Minnesota who was denied coverage for continued rehabilitation for a broken leg and a North Carolina woman who incurred $24,000 in out-of-pocket medical expenses because Humana denied treatment at a skilled nursing facility for several diagnoses, including sepsis and acute kidney failure. They claim the insurer used nH Predict to override treating physicians’ determinations for medically necessary care even though the predictions are known to be highly inaccurate and not based on patients’ medical needs.
“Despite the high rate of wrongful denials, Humana continues to systemically use this flawed AI Model to deny claims because they know that only a tiny minority of policyholders (roughly 0.2%) will appeal denied claims, and the vast majority will either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care,” the lawsuit claims. “Humana banks on the patients’ impaired conditions, lack of knowledge, and lack of resources to appeal the wrongful AI-powered decisions.”
HHS FINALIZES RULE ON HEALTH IT INTEROPERABILITY, ALGORITHM TRANSPARENCY
The U.S. Department of Health and Human Services (HHS) through the Office of the National Coordinator Health Information Technology (ONC) has finalized a final rule to advance patient access and interoperability. The rule establishes transparency requirements for artificial intelligence (AI), and other predictive algorithms that are part of certified health IT; adopts the United States Core Data for Interoperability Version 3 as the new baseline standard within the ONC Health IT Certification Program; enhances information blocking requirements; and implements new interoperability-focused reporting metrics for certified health IT.
CMS OFFERS GUIDANCE TO IMPROVE ACCESS TO HOME- AND COMMUNITY-BASED SERVICES
The Centers for Medicare & Medicaid Services (CMS) this week released guidance that outlines how states can establish tools to connect individuals who need care with those qualified to provide it. The guidance focuses on building and maintaining worker registers so more individuals who receive Medicaid-covered services can receive care in a setting of their choice. “For too long, American families have struggled to find and afford reliable high-quality care that enables their loved ones to live independently. Some people are forced to forgo their careers and stay home to care for a family member, and many caregivers struggle to make living wages. Thanks to President Biden and the American Rescue Plan, that changes today,” said HHS Secretary Xavier Becerra in the announcement. The administration, he said, has distributed $37 billion from the American Rescue Plan across all 50 states for home- and community-based services.
NEW REPORT SHOWS PROMISE OF MA SUPPLEMENTAL BENEFITS TO ADDRESS AGING IN PLACE
A new report by Faegre Drinker Biddle & Reath LLP provides insight into the 2024 preventive supplemental benefit landscape in Medicare Advantage. Benefits, such as home and bathroom safety modifications, grew 120 percent from 2023 to 2024, according to the report. Memory fitness benefits experienced an eight percent increase in 2024. The trends indicate a strategic shift to focus on benefits toward aging in place and maintaining the physical and mental health of members. The report notes that benefits that enhance the quality of life for members, such as support for caregivers and medical nutrition therapy, have room for growth. “The continuous evolution of these benefits will likely shape the next generation of Medicare Advantage offerings, ensuring comprehensive care and enhanced quality of life for beneficiaries,” the report said. “This progression promises not only to redefine the standards of elderly care but also to set a benchmark for holistic, patient-centered health care solutions in the years to come.”
CALIFORNIA WOMAN SENTENCED TO 15 YEARS IN PRISON FOR $24M SCAM
A 55-year-old woman from Redondo Beach, Calif. was recently sentenced to 180 months in federal prison for billing Medicare more than $24 million by submitting fraudulent claims for medically unnecessary durable medical equipment, mostly power wheelchairs and repairs for them, many of which were never performed.
The Department of Justice said Tamara Yvonne Motley, 55, a.k.a. “Tamara Ogembe,” was sentenced by United States District Judge Stanley Blumenfeld Jr., who also ordered her to pay $13,107,422 in restitution as well as an additional $2,300 in special assessments. She was found guilty after a jury trial in June of 20 counts of health care fraud, two counts of aggravated identity theft, and one count of conspiracy to commit money laundering.
According to DOJ, from 2006-2016, Motley was the defector owner of two medical equipment companies and orchestrated a scheme in which she paid marketers for patient referrals and then directed them to take patients to corrupt physicians, who prescribed medically unnecessary durable medical equipment, such as power wheelchairs, that the companies used to submit fraudulent bills to Medicare. In 2011, when Medicare changed the reimbursement rules to make upfront payments less lucrative, the company switched to billing Medicare for repairs to the wheelchairs.
“[Motley] manipulated those around her to serve her criminal ends,” prosecutors argued in a sentencing memorandum. “She used relatives and employees to conceal her role in the scheme, and even used her infant’s caretaker to carry out the illegal activities of her scheme. She took advantage of vulnerable Medicare beneficiaries in far-flung places like Calexico who were elderly and often non-English speaking. She deceived inspectors to preserve her companies’ accreditation with Medicare.”