A new federal watchdog audit is ratcheting up pressure on government officials to crack down on billions of dollars in overcharges linked to Medicare Advantage home visits.
But so far, the Centers for Medicare & Medicaid Services has rejected a recommendation from the Health and Human Services Inspector General to limit payments stemming from house visits that don鈥檛 result in any medical treatment 鈥� a potential red flag that may signal overcharges.
In , the HHS watchdog found that the health plans pocketed $7.5 billion in 2023 from diagnosing health conditions that prompted no medical services 鈥� about $4.2 billion of it through health assessments done in patients鈥� homes. And court records show that for a decade or more, CMS officials have failed to act on their concerns that the home visits waste tax dollars and should be limited.
UnitedHealthcare, the largest Medicare Advantage contractor, accounted for about two-thirds of the payments tied to home visits and chart reviews, in which health plans mine patient medical files to add new diagnoses that can bring in additional revenue, according to the audit.
Assistant Inspector General Erin Bliss said the health plans are making billions without offering any treatment for medical conditions they flag during the visits, such as diabetes and major depression.
鈥淔rankly, it needs to stop,鈥� Bliss said.
CMS, which runs the Medicare program, disagrees.
In a statement to 杨贵妃传媒視頻 Health News by spokesperson Alexx Pons, the agency said it 鈥渁ppreciates the OIG鈥檚 review in this area鈥� and will continue to study the issue.
However, CMS disagreed with the OIG鈥檚 call to restrict use of home health assessments in computing how much to pay health plans. People on Medicare 鈥渟hould have access to care that is appropriately provided in the home setting,鈥� CMS wrote in a written response included in the audit report.
鈥淥ne would think that CMS would kick its regulatory oversight up a notch or two,鈥� said Richard Lieberman, a Colorado health data analytics expert.
鈥淚n contrast, CMS appears to be unconcerned and is telling OIG to stay out of their lane,鈥� he said.
UnitedHealthcare spokesperson Heather Soule said in a statement that the OIG had drawn 鈥渋naccurate conclusions鈥� in the audit.
The home visits are 鈥渁mong the most comprehensive and thorough assessments of a patient鈥檚 health and physical environment available in the healthcare system, helping to identify and drive needed follow-on care for the vast majority of the patients with whom we engage,鈥� according to the company.
No Care Provided
Government spending on Medicare Advantage, which is dominated by UnitedHealthcare and a handful of other health insurance companies, is expected to hit this year.
The industry, whose more than 33 million members make up over half of people eligible for Medicare, most enrollees are satisfied with the care they receive and typically pay less out-of-pocket than those on original Medicare.
Whether Medicare Advantage is a good deal for taxpayers is another matter, largely because many health plans exaggerate how sick patients are to boost their payments, multiple and other investigations have shown. Medicare pays the health plans higher rates for sicker patients.
For fiscal year 2023, CMS identified $12.7 billion in overpayments linked to diagnoses not supported by patients鈥� medical records.
The OIG audit tied $7.5 billion in payments to health conditions that prompted no treatment, including serious diseases such as diabetes, congestive heart failure, and major depression. That suggests that the medical condition either didn鈥檛 exist or that the health plan failed to treat it adequately, auditors said.
鈥淭hese are serious conditions. You would think you would see additional care during that year,鈥� said Jacqualine Reid, who led the OIG audit team. 鈥淲e are asking CMS to step up its oversight.鈥�
Homegrown
The in-home visits have sparked controversy for more than a decade. A June 2014 found that a sharp rise in home visits had inflated Medicare鈥檚 costs by billions of dollars. The visits, which typically last less than an hour, are often conducted by nurse practitioners, who do not treat the patient, but go over a checklist of possible health conditions.
Sabrina Skeldon, a Texas lawyer who advises physicians on billing issues, said problems arise when health plans fail to order necessary medical tests to confirm a diagnosis made during a home visit 鈥� and treat it.
Skeldon noted that The Cigna Group in 2023 paid $172 million that alleged its Medicare Advantage plan illegally collected payments for medical diagnoses that were based solely on in-home assessments.
The OIG audit comes as the Justice Department presses a that accuses UnitedHealth Group of cheating Medicare out of more than $2 billion by mining patient records to churn up diagnoses that boosted revenue, while ignoring evidence of overpayments. The company denies the allegations.
Court filings from the case show CMS officials were concerned years ago that home visits and chart reviews could needlessly drive up costs.
In April 2014, CMS a proposal to restrict their use amid complaints from the industry that it would lose billions of dollars as a result. Similarly, CMS officials scrapped a proposal to tighten scrutiny on the chart reviews after what one official called an 鈥渦proar鈥� from the industry.
CMS officials also had concerns that unchecked home visits might affect efforts to recover overpayments through billing reviews known as 鈥淩ADV鈥� audits.
Former CMS official Thomas Hutchinson, who ran the agency鈥檚 Medicare Plan Payment Group from September 2006 through June 2010, testified in a deposition that officials had 鈥渉eard about various folks that figured out how they could RADV-proof things by doing in-home visits.鈥�
In a confidential April 2015 slide presentation, CMS officials observed that health plans were 鈥渘ow conducting health risk assessments in beneficiaries鈥� homes. One purpose of the assessments is to identify conditions and create medical records documentation that substantiates diagnoses.鈥�
And an October 2015 CMS memo circulated among senior agency staff cites 鈥渓imitations around home visits鈥� among the possible ways to 鈥渟trengthen鈥� the RADV audits.
In its statement to 杨贵妃传媒視頻 Health News, CMS said it was 鈥渃ommitted鈥� to ensuring that diagnoses health plans submitted for payment were accurate. But the agency declined to answer written questions about the impact of home visits on its audit program, which has yet to complete reviews of payments dating back as far as 2011.
UnitedHealthcare had the lowest rates of unconfirmed diagnoses among five large Medicare Advantage organizations audited in 2011, according to court records.
Overall, the company ended up with underpayments of more than $261 million for 15 of its plans audited for 2011-2013, court records show. The audit findings for other Medicare Advantage firms are blacked out in court filings.
CMS audits payments to just 30 out of more than 700 contracts a year. That鈥檚 not enough to protect tax dollars, said Matthew Fiedler, a health policy researcher at The Brookings Institution.
鈥淭hey should be auditing 10 times as many contracts,鈥� he said. 鈥淲here we are now you are not likely to get caught.鈥�