JustCare

Tag: Home visit

  • New OIG report finds taxpayers pay billions extra for Medicare Advantage insurers’ in-home visits

    New OIG report finds taxpayers pay billions extra for Medicare Advantage insurers’ in-home visits

    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:

  • Home visits: Another way Medicare Advantage plans gouge taxpayers

    Home visits: Another way Medicare Advantage plans gouge taxpayers

    Policymakers who claim to be tough on crime continue to turn a blind eye to what appears to be multi-billion dollar corporate health insurer crimes in Medicare Advantage. Anna Wilde Mathews and colleagues report for The Wall Street Journal on millions of home visits to Medicare Advantage enrollees that increased insurer revenues by $15 billion in three years.

    The government’s defective payment system to insurers rewards them for adding diagnoses codes to their enrollees’ medical records. When nurses conduct homes visits, they identify new diagnoses that increase insurer revenues from the government. Insurers can add diagnosis codes to enrollee records even if a doctor doesn’t perform a procedure to treat the diagnosis.

    By the WSJ’s account, the nurses conduct screenings during their home visits that permit the insurers to collect $1,818 more on average per visit. In total, between 2019 and 2021, those visits lined the insurers’ pockets by an additional $15 billion.

    UnitedHealth was best equipped to squeeze money out of those nurse home visits, collecting $2,735 per visit on average. It conducted 2.7 million nurse visits last year alone. Humana did a relatively good job of maximizing revenues from those home visits, collecting $1,525 per visit on average. CVS/Aetna received an additional $232 per nurse home visit.

    One former UnitedHealth nurse explained that she did an average of six home visits each day. As part of the visit, she would warm up people’s toes to see how well blood flowed to them. The goal was to diagnose them with peripheral artery disease, which would mean an average of $2,500 a year more for UnitedHealth.

    The nurse said she did not believe that the device she used for the test worked properly to diagnose peripheral artery disease. But, no one seemed to care, and she was told to keep using it. UnitedHealth added the diagnosis to 568,000 medical records over the three years, as a result of using this device.

    “Other nurses interviewed by the Journal said many of the diagnoses that home-visit companies encouraged them to make wouldn’t otherwise have occurred to them, and in many cases were unwarranted.”

    UnitedHealth received $1.4 billion from the peripheral artery disease diagnosis. Medicare says it is no longer making additional payments to insurers for peripheral artery disease diagnoses.

    UnitedHealth appears to take the cake when it comes to additional patient diagnoses from the nurse home visits. Its nurses detected hyperaldosteronism 246,000 times over the three-year period the WSJ investigated, which was worth $450,000 to the company. All other insurers combined diagnosed the condition less than 24,000 times and collected $42 million as a result.

    The WSJ had previously reported that insurers billed Medicare $50 billion for enrollee health conditions that physicians never treated. Of that, thirty percent stemmed from nurse home visits. The WSJ found that many diagnoses were wrong or questionable.

    To be sure, a nurse’s home visit could be helpful to a patient. The nurse could help with medication management, for example. But, considering that the WSJ found little if any follow-up after these nurse visits, the real benefits is to the bottom lines of the health insurance companies offering Medicare Advantage.

    Here’s more from Just Care: