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inpatient care, denials of long-term acute care, rehab, lab tests and medical equipment. The Inspector General said that “human error” and “system processing error” caused most of the Official The Peanuts Characters Charlie Brown Christmas Snoopy Shirt and I love this denials by Medicare Advantage plans. But the hospital executives NBC News spoke with say they believe the denials are a strategy by insurers to improve their profits by refusing to pay claims. “This world of medical billing is so automated if you’re denying a claim, you’re doing it intentionally,” said Martin, of San Luis Valley Health. UnitedHealthcare declined to comment. The Cuero Regional Health System, a small hospital in Cuero, Texas, serves a population of 22,000. Its officials say Medicare Advantage plans often deny care based on the insurers’ internal determinations about the type of care required, overruling the physicians handling the cases. When the hospital questions a determination — called a peer-to-peer review — officials often have to argue with a physician who doesn’t specialize in the care the patient requires, said Lynn Falcone, its chief executive. A Medicare Advantage plan recently denied a referral to long-term acute care for a patient with sepsis, Falcone said. When the family practice doctor overseeing the case asked for a peer-to-peer review,
the Official The Peanuts Characters Charlie Brown Christmas Snoopy Shirt and I love this insurance company physician defending the denial was an ob-gyn specialist. “A surgeon that delivers babies maybe isn’t used to handling sepsis,” Falcone said. This spring, Dr. Kenneth Williams had to shut down a longtime geriatric psychiatry program that had served the local community for over eight years. Andrea Morales for NBC News ‘It had to be extreme’ Sandra Tate of Cuero, Texas, said her family’s Medicare Advantage plan created problems for her family in Feb. 2022. Her husband required physical and respiratory therapy after a 10-day stay in the ICU at Cuero Regional Health, she said; although a previous plan from Humana had paid for this treatment four years earlier, the second request for reimbursement was denied under her new plan from United Healthcare. After arguing with the insurer for 30 minutes, Tate, a former school nurse, said she was never told why. “I pay my Medicare premiums and also my insurance premiums,” Tate told NBC News. “I don’t understand why Medicare Advantage
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