Nearly 97% of UnitedHealth’s in-home Medicare Advantage diagnoses were supported by a patient’s medical record in 2025, according to a review commissioned by the company.
The findings are the latest in UnitedHealth’s efforts to defend HouseCalls, the in-home care program under Optum that has been under intense scrutiny from federal lawmakers, the Justice Department and media reporting on Medicare Advantage upcoding for years. Despite the scrutiny, MA-specific enforcement action against UnitedHealth has not materialized to date.
For the review, UnitedHealth hired FTI Consulting to examine 200 randomly selected HouseCalls visits from 2025 and 494 Member-HCCs, the diagnosis groupings CMS uses to calculate MA risk scores. Using medical records alone, FTI found 96.6% of sampled Member-HCCs were supported, or a 3.4% error rate.
UnitedHealth compared its error rate to a 4.94% net payment error rate CMS found across the Medicare Advantage program overall in 2023, a 9.4% error rate CMS found specifically among Member-HCCs in 2023, and a 5% threshold CMS applies in Risk Adjustment Data Validation-related audits.
UnitedHealth also said that 99% of sampled diagnoses were supported by medical records or paid claims. Of 17 diagnoses FTI could not initially validate from the HouseCalls record alone, UnitedHealth said it went back through the patient’s broader care history and found support, including in paid claims, for most of them. FTI’s second-pass review then confirmed 12 of the 17.
The review is part of a larger internal audit program that UnitedHealth CEO Stephen Hemsley launched in mid-2025, shortly after the company disclosed it was cooperating with civil and criminal DOJ requests tied to its Medicare Advantage billing practices. Consultant groups retained and paid by UnitedHealth delivered an initial round of findings in December, covering risk adjustment operations, UnitedHealthcare’s care services management and Optum Rx’s manufacturer discount practices. Those reviews said the company’s policies were “robust, rigorous and generally sound” while recommending governance and documentation improvements, including for the HouseCalls program specifically.
HouseCalls, which sends nurse practitioners and other clinicians into members’ homes for annual wellness visits, has drawn scrutiny for years as a channel UnitedHealth allegedly used to capture diagnoses that raised Medicare Advantage risk scores and payments.
In January, a Senate report from Sen. Chuck Grassley (R-Iowa), based on 50,000 pages of UnitedHealth documents, found the company used “aggressive strategies,” including home visits, physician bonuses and AI-assisted chart reviews, to capture higher-paying MA diagnoses tied to $8.7 billion in 2021 federal payments, without alleging misconduct.
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