Christopher Weaver and others report for The Wall Street Journal on how Medicare Advantage insurers game the payment system. They reap tens of billions of additional dollars each year through false claims that their enrollees have health conditions that they do not really have. The Medicare Advantage payment system is defective, cheating taxpayers. What will it take for Republicans and Democrats in Congress to eliminate these overpayments and reform the payment system in Medicare Advantage?
The Medicare Advantage plans hire nurses to visit enrollees and identify additional health conditions for them. They even give $50 gift cards to enrollees who allow these nurses to visit them at home. With new diagnosis codes on patient records, Medicare pays Medicare Advantage insurers billions of additional dollars, driving up Part B premiums for everyone with Medicare and ripping off taxpayers.
UnitedHealth is one of the insurers that engages nurses to visit their enrollees at home. In some cases, nurses find “diabetic cataracts” which leads to as much $2,700 in additional Medicare payments for a single enrollee in a year. But, sometimes, if not more often than that, the enrollee has neither diabetes nor cataracts, the Wall Street Journal found in an analysis of Medicare records.
Dr. Howard Chen, an ophthalmologist in Arizona, said he had one or two patients each year with diabetic cataracts. But, UnitedHealth reported to Medicare that 148 of his patients had this condition. Compared to patients in Traditional Medicare, UnitedHealth enrollees were 15 times more likely to have diabetic cataracts. When told about this odd disparity, eye experts said that it was not plausible that so many UnitedHealth enrollees could have this condition.
The Wall Street Journal also found that insurers who add additional diagnoses to patient records often do not provide care to patients with these diagnoses. Even when the additional diagnoses were for deadly conditions that would require treatment, such as AIDS, the insurer provided no follow-up care.
UnitedHealth reported $8.7 billion for diseases they never treated, such as HIV in 2021. UnitedHealth also kept a Hepatitis C diagnosis on records of more than half of their patients who had completed treatment for the condition and had been cured.
The WSJ findings add to a chorus of findings from an array of independent experts, revealing the defective Medicare Advantage payment system. Taxpayers have spent more than half a trillion dollars—$591 billion— on Medicare than they would have spent had Medicare Advantage never been enacted, according to the Medicare Payment Advisory Commission. This privatized Medicare Advantage program has been a bust from a cost perspective.
What’s worse is that Medicare Advantage plans too often deny care inappropriately to enrollees who need costly care. And, still worse, the government has little ability to oversee the insurers offering Medicare Advantage, let alone punish the criminal insurers in a meaningful way. The Centers for Medicare and Medicaid Services, which oversees Medicare, is hard-pressed to cancel their contracts.
UnitedHealth disputed the WSJ findings saying they were “inaccurate and biased.” But, it provided no evidence to support its claim. In contrast, the WSJ found 66,000 patients diagnosed with diabetic cataracts, when it was not possible. They had had cataract surgery and could not have had cataracts!
Here’s more from Just Care:
- Justice Department going after Medicare Advantage fraud
- Medicare fraud: Traditional Medicare v. Medicare Advantage
- Fraudsters banned from the Medicare program circumvent the ban
- Medicare Advantage: Combating fraud is a challenge because there’s no data on denied claims
- Whistleblowers expose fraudulent Medicare Advantage billing practices