For years, government agencies and independent experts have reported that Medicare Advantage insurers game the Medicare payment system to generate billions of dollars in extra revenue from the government. A new report from the Office of the Inspector General focuses on how insurers use home visits as a way to add diagnoses to enrollee medical records and increase their Medicare reimbursements.
The government pays Medicare Advantage insurers a flat upfront amount for each enrollee. The amount is based on what the government spends in traditional Medicare. But, the government increases that amount for “sicker” patients–patients with more diagnosis codes.
So, insurers do what they can to increase the amount they get from the government; they “upcode” or add diagnosis codes to enrollee records. They engage nurses to visit enrollees at home and identify more diagnoses for these enrollees. The home visits could be value-added if the insurers provided care tailored to these diagnoses. But, the OIG reports that Medicare Advantage insurers generally simply bill the government more for these enrollees. They do not conduct follow-up visits or deliver other services related to the added diagnoses.
On average, the insurers generate an extra $1,869 from each home visit. In fiscal year 2023, these visits translated into $3.73 billion for UnitedHealth alone. Not surprisingly, UnitedHealth contends that the home visits add value to the care they provide.
What additional diagnoses did the nurses who conducted home visits tend to find? They found vascular disease, depression, morbid obesity, chronic obstructive pulmonary disease and rheumatoid arthritis most frequently. They also found enrollees with complications resulting from their diabetes.
Now what? The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, has never been successful at recouping the overpayments. But, it has ended payment to insurers for certain diagnosis codes that are commonly added during in-home visits and do not result in further treatment. It’s a start, but CMS clearly needs to do a lot more.
Here’s more from Just Care:
- Comment to CMS on its proposed changes to the way it calculates Medicare Advantage payments in 2024
- Ten ways to improve Medicare Advantage
- Evidence abounds that Medicare Advantage needs an overhaul
- Insurers pay Medicare Advantage brokers to steer you away from Traditional Medicare
- Medicare for all improves the lives of older adults
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