Pressure Rises on Government Body
A recent federal watchdog review has escalated concern about potential overcharges in Medicare Advantage home visits. This is adding pressure on government officials to tackle these excess charges amounting to several billions of dollars. However, the Centers for Medicare & Medicaid Services (CMS) has not yet curtailed payments linked to home visits that don’t lead to medical treatment, often seen as a sign of overcharging.
Audit Reveals Hefty Figures
At the conclusion of October, the federal review highlighted that health plans had gained a considerable $7.5 billion. This huge sum was generated in 2023 from identifying health conditions that didn’t lead to any medical services. Shockingly, about $7.5 billion of these funds came from health assessments conducted in patients’ homes. For over a decade, officials seemed to neglect their worries that these home visits were a drain on tax dollars and should be reduced.
Primary Beneficiary: UnitedHealthcare
UnitedHealthcare, the most significant Medicare Advantage contractor, accounted for approximately two-thirds of payments tied to home visits and chart reviews. In these chart reviews, health plans scrutinize patient medical records to find new diagnoses that can bring in more money.
Assistant Inspector General Erin Bliss called out the health plans for pocketing billions, yet not providing treatment for severe medical conditions identified during the visit. Conditions included severe mental illnesses like major depression and serious physical disorders like diabetes. Bliss stated that this practice needs to stop.
CMS Reaction: Unconcerned
The CMS, which manages the Medicare program, opposed this suggestion. In their view, people on Medicare should have access to care appropriately given within the home setting. Critics point out that this stance might indicate a lack of interest from CMS and a reluctance to take proactive action.
Undeterred by Criticism
UnitedHealthcare defended itself, stating that the federal watchdog drew incorrect conclusions from the audit. The company highlighted that its home visits provide extensive reviews of a patient’s health and environment. It asserts these visits help identify needed care for the majority of patients.
Potential Concerns
Debate continues over whether Medicare Advantage, which is chiefly controlled by UnitedHealthcare and several other health insurance providers, offers value for tax dollars. Various federal reviews and other investigations have shown that many health plans exaggerate how sick patients are to push their payments upward.
Overpayments and Untreated Conditions
In the fiscal year 2023, CMS identified an alarming $12.7 billion in overages linked to diagnoses not supported by patients’ medical records. Auditors have tied $7.5 billion of this sum to health conditions that did not result in treatment. Conditions such as diabetes, congestive heart failure, and major depression were diagnosed but remained untreated, signalling potential inaccuracies in the diagnosis or inadequate treatment by the health plan.
The Ongoing Issue with Home Visits
Home-based medical visits have sparked substantial debate for more than 10 years. A media investigation revealed that a significant increase in home visits has inflated Medicare’s costs by billions. These visits usually last less than an hour and typically involve a nurse practitioner’s assessment rather than actual treatment.
In a recent example, the Cigna Group was found guilty of illegally collecting payment for diagnoses based purely on home assessments and had to resolve the issue by paying a hefty $172 million in settlement.
There is also an ongoing civil fraud case against UnitedHealth Group. The Justice Department is accusing the company of causing Medicare losses worth above $2 billion. This is supposedly by churning up diagnoses that enhanced revenue while ignoring evidence of overpayments, allegations which the company denies.
Calls for Greater Scrutiny and Oversight
The CMS audits only 30 out of above 700 contracts a year. According to Matthew Fiedler, a health policy researcher, this is insufficient to protect tax dollars. Critics urge CMS to increase audits and step up its oversight to ensure protection of taxpayer money and maintain the integrity of the Medicare Advantage program.