Saturday, March 28, 2026

The Schall Law Firm opened an investigation into CVS/Aetna for using AI to improperly deny prior authorization for post-acute care — skilled nursing, rehab, and home health — for Medicare Advantage patients. The Senate Permanent Subcommittee on Investigations found CVS's post-acute denial rate was 3x higher than its overall PA denial rate in 2022. A class-action lawsuit alleges Aetna deployed AI to override physician recommendations without individualized patient review. Policyholders can now join.

MA plans must publish aggregate PA approval/denial metrics by March 31. First reporting cycle. 72-hour expedited decisions and 7-day standard decisions enforced since January 1. Plans must disclose turnaround times, denial rates, appeal rates, and overturn rates at the contract level. Service-level data was killed — only aggregates. The pre-written X thread must be finalized and ready to deploy Monday morning.

Congress's $50B Rural Health Transformation Fund — created as a sweetener in the One Big Beautiful Bill Act — may force rural hospitals to cut services, not expand them. Montana is one of at least 10 states where the fund's rules incentivize "right-sizing" (downsizing) inpatient services. 380 independent rural hospitals are at risk of closure nationwide. The fund pays hospitals for implementing recommendations, including service cuts. Commonwealth Fund senior adviser Tony Shih: "If high-margin services are taken away from local hospitals with nothing given back in return, it can be financially harmful."

UnitedHealth (nH Predict, 90% error rate, court-ordered disclosure) and CVS/Aetna (AI-driven PA denials, class action open) now face simultaneous legal action over algorithmic claim denials. Stanford/Health Affairs research published in January found 84% of large insurers use AI for coverage decisions. Human reviewers spend an average of 1.2 seconds per case. The algorithms are trained on past denial decisions, locking in existing flaws. 71% of insurers surveyed by NAIC confirmed AI use in utilization management.

CEO attestation required starting April 1. Machine-readable files must include median allowed amounts plus 10th/90th percentile, derived from electronic remittance advice. 35% CMP reduction available if hospitals waive hearing rights — but not for missing core files. Three years of grace period end Wednesday. Two regulatory deadlines converging in 4 days.