Introduction
Medicare Advantage (MA) plans have come under scrutiny for their financial practices related to home visit diagnoses. A recent investigation by The Wall Street Journal (WSJ) revealed that insurers have made billions of dollars by adding diagnoses to Medicare Advantage beneficiaries’ charts during home visits. This practice has sparked debates over its legitimacy and impact on federal spending. This article delves into the WSJ’s findings, the role of major insurers like UnitedHealth Group, and the federal government’s response.
The Financial Impact of Home Visits in Medicare Advantage
Medicare Advantage plans receive payments based on the health diagnoses of their beneficiaries. This payment model incentivizes insurers to add more diagnoses, which can lead to higher reimbursements from the federal government. According to WSJ, many of these added diagnoses occur during home visits, raising questions about their accuracy and necessity.
Investigative Findings by The Wall Street Journal
Questionable Diagnoses
The WSJ’s investigation uncovered that Medicare Advantage insurers gained $50 billion from added diagnoses between 2018 and 2021. A significant portion of these diagnoses were labeled as “questionable,” suggesting that they may have been exaggerated or unnecessary. Approximately one-third of these diagnoses were added during home visits, intensifying the concerns over their validity.
Peripheral Artery Disease Example
One striking example from the WSJ report involves over 700,000 diagnoses of peripheral artery disease made during home visits between 2019 and 2021. These diagnoses resulted in $1.8 billion in payments to insurers. This case exemplifies the potential for financial gain through the addition of diagnoses during home visits.
UnitedHealth Group’s Role and Defense
Executive Statements and Investor Call Highlights
UnitedHealth Group, one of the largest MA insurers, received $2,735 per beneficiary for diagnoses added during home visits—the highest amount among insurers. Dr. Wyatt Decker, executive vice president and chief physician of UnitedHealth Group, defended the practice, stating that their patient population is sicker than those of other insurers and that their nurse practitioners are highly effective.
During a July 16 call with investors, UnitedHealth CEO Andrew Witty highlighted the benefits of their home-visit program. He claimed that home visits identified 300,000 older adults with emergent health needs that might have otherwise gone undiagnosed. Witty asserted that these programs help patients live healthier lives and save taxpayers money.
Federal Government’s Financial Burden and Recommendations
Medicare Payment and Advisory Commission Findings
The Medicare Payment and Advisory Commission (MedPAC) estimates that the federal government will spend $83 billion more on Medicare Advantage beneficiaries compared to those enrolled in fee-for-service Medicare. MedPAC predicts that coding intensity in MA will be 20% higher than in fee-for-service Medicare by 2024. These findings underscore the financial impact of the current payment model.
Recommendations and CMS Actions
MedPAC has recommended that insurers should not be paid for diagnoses added through home visits. In response, a spokesperson for the Centers for Medicare & Medicaid Services (CMS) told the WSJ that the agency is increasing audits to verify diagnoses in MA beneficiaries’ charts. Additionally, CMS plans to eliminate some diagnoses that currently qualify for extra payments.
Conclusion
The WSJ investigation sheds light on the financial strategies employed by Medicare Advantage insurers through home visit diagnoses. While insurers like UnitedHealth Group defend the practice as beneficial for patient care and cost savings, the federal government faces a substantial financial burden. With recommendations from MedPAC and increased audits by CMS, the future of home visit diagnoses in Medicare Advantage remains uncertain.
Discover the latest payers’ news updates with a single click. Follow DistilINFO HealthPlan and stay ahead with updates. Join our community today!
FAQs
Q: What did the WSJ investigation reveal about Medicare Advantage home visits?
A: The WSJ investigation found that insurers made billions from diagnoses added to Medicare Advantage beneficiaries’ charts during home visits, with many diagnoses being questionable.
Q: How much did Medicare Advantage insurers gain from added diagnoses between 2018 and 2021?
A: Insurers gained $50 billion from added diagnoses between 2018 and 2021, with a significant portion added during home visits.
Q: What is UnitedHealth Group’s stance on home visit diagnoses?
A: UnitedHealth Group defends the practice, claiming it helps identify emergent health needs and improves patient care while saving taxpayers money.
Q: What are MedPAC’s recommendations regarding home visit diagnoses?
A: MedPAC recommends that insurers should not be paid for diagnoses added through home visits and has advised CMS to increase audits and eliminate some qualifying diagnoses.
Q: How is the federal government responding to the findings on home visit diagnoses?
A: The federal government, through CMS, is ramping up audits to verify diagnoses and plans to eliminate certain diagnoses that currently qualify for extra payments.
