The Senate Judiciary Committee just confirmed what we’ve been hearing for several years now, UnitedHealth games the Medicare Advantage program’s payment system to boost its profits, driving up Medicare premiums and eating into the Medicare Trust Fund. Christopher Weaver and Anna Wilde Matthews report for The Wall Street Journal on the Committee’s report. The open question is whether Congress or the administration will do something to claw back the tens of billions of dollars in overpayments to UnitedHealth and to ensure the overpayments do not continue.
Republican Senator Chuck Grassley, Chair of the Senate Judiciary Committee, said that UnitedHealth aggressively added diagnosis codes to its enrollees’ medical records in order to boost its Medicare payments. Medicare pays insurers a base flat fee for each enrollee and an additional amount when enrollees have certain diagnoses, on the theory that they will use more care.
The Judiciary Committee was following up on a Wall Street Journal investigation of UnitedHealth last year that found UnitedHealth “systematically” added diagnoses codes to enrollees’ medical records, which generated billions of dollars in additional revenue for the corporation. Often, enrollees were not getting treated for the conditions listed in their medical records.
Right now, the Justice Department is investigating UnitedHealth for civil and criminal violations. Of course, without any evidence, UnitedHealth claims its innocence and argues the Wall Street Journal’s findings were erroneous. AARP, which collaborates with UnitedHealth and markets its Medicare Advantage and other products to its members in return for a multi-year $9 billion payout, remains silent on the matter.
Shockingly, the Judiciary Committee does not recommend additional action against UnitedHealth nor does it say UnitedHealth has done anything wrong. Yet, it reveals UnitedHealth’s multi-pronged strategy–through enrollee home visits, physician bonuses, AI and more– used “to the utmost degree” to boost enrollee diagnoses.
In some cases, providers added diagnoses without medical testing. For example, UnitedHealth advised a diagnosis of opioid dependence when an enrollee was taking opioids, even when there was no evidence of dependence. Indeed, UnitedHealth advised keeping that diagnosis after enrollees went off the opioids, claiming they were “in remission.” UnitedHealth guidelines for its employees also directed them to add a diabetic cataract diagnosis for patients who had had their cataracts removed!
Of late, Medicare stopped paying for some of the diagnoses that UnitedHealth was adding to enrollee records. Time will tell whetherUnitedHealth adds new diagnosis codes to enrollee records in order to boost revenue.
Here’s more from Just Care:
- 2026: Big changes in Medicare Advantage
- Ten ways Medicare Advantage plans differ from traditional Medicare
- 2026: Five things to think about when choosing between Traditional Medicare and a Medicare Advantage plan
- Medicare Advantage inappropriate denials of care abound
- OIG finds widespread inappropriate care denials in Medicare Advantage
