Insurers made billions from diagnoses added to Medicare Advantage beneficiaries' charts during home visits, The Wall Street Journal found in an investigation published Aug. 5.
Previous reporting from the Journal found that MA insurers made $50 billion from diagnoses added to patients charts between 2018 and 2021. Many of these diagnoses were "questionable," according to the Journal.
Around a third of these diagnoses were added during home visits, the Journal reported. The federal government pays Medicare Advantage plans a rate per beneficiary based on their diagnoses.
In one example, more than 700,000 diagnoses of peripheral artery disease were made during home visits to MA beneficiaries in 2019 to 2021, totaling $1.8 billion in payments for insurers.
UnitedHealth Group received $2,735 per beneficiary for diagnoses added during home visits according to the Journal, the most of any insurer.
Wyatt Decker, MD, executive vice president and chief physician of UnitedHealth Group, told the Journal UnitedHealth's patient population is sicker than other insurers and its nurse practitioners are highly effective at their jobs.
On a July 16 call with investors, Andrew Witty, CEO of UnitedHealth, touted the company's home-visit program. Home visits identified 300,000 older adults with emergent health needs that may have otherwise gone undiagnosed, Mr. Witty said.
"Our home-visit programs help patients live healthier lives and save taxpayers money," Mr. Witty said.
In a statement published Aug. 8, UnitedHealth Group said the Journal investigation "fundamentally misrepresents" its HouseCalls business.
"The professionally licensed and highly trained HouseCalls clinicians — many of whom have been dedicated to visiting Medicare Advantage seniors for years as part of this program — perform health, home and environmental assessments and offer preventive services, but they do not prescribe or order treatments," the company said. "They may refer members to other services or providers, but they always direct members back to their chosen, treating physician for treatment."
The federal government will spend $83 billion more on Medicare Advantage beneficiaries than if they were enrolled in fee-for-service Medicare, according to estimates from the Medicare Payment and Advisory Commission. Coding intensity in MA will be 20% higher than in fee-for-service in 2024, according to the commission, which advises the federal government on Medicare issues.
The commission has recommended that insurers should not be paid for diagnoses added through home visits.
A spokesperson for CMS told the Journal the agency is ramping up audits to verify diagnoses in MA beneficiaries charts. CMS will also eliminate some diagnoses that qualify for extra payments, the spokesperson said.
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