According to a Wall Street Journal article from August 4, Medicare Advantage plans are using home nurse visits to identify possible or questionable disease states/conditions (so called, phantom diseases) via screenings. These diagnoses then turn into what appears to be, possible events of fraud via additional reimbursement tied to these new-found conditions. Exclusive | The One-Hour Nurse Visits That Let Insurers Collect $15 Billion From Medicare – WSJ
Annually, insurers dispatch nurses to the homes of Medicare beneficiaries millions of times to conduct examinations, perform tests, and ask numerous questions. These nurses are not present to provide treatment; rather, they are there to identify new diagnoses that qualify private Medicare Advantage insurers to receive additional funds from the federal government.
According to the Wall Street Journal investigation, Medicare Advantage insurers utilized home visits by nurses to conduct screening tests and record atypical diagnoses. These actions transformed the approximately hour-long visits into an additional average revenue of $1,818 per visit from 2019 to 2021. The total payments amounted to roughly $15 billion over that time frame, as reported by a Journal analysis of Medicare data.
Some of the nurses interviewed said many of the diagnoses that home-visit companies had them make wouldn’t otherwise have occurred to them, and in many instances were unwarranted or “phantom”.
The government provides insurers with a base rate for each Medicare Advantage enrollee. Additionally, insurers receive supplementary funds when their patients are diagnosed with specific conditions that require expensive treatment.
In a preceding article from July, the Wall Street Journal observed that insurers are making new diagnoses by reviewing medical charts, occasionally utilizing artificial intelligence, and dispatching nurses for home visits with patients. They compensate doctors for access to patient records and offer patients financial incentives, such as gift cards, for consenting to home visits. Exclusive | Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated – WSJ
An example cited in the article involved diabetic cataracts (diagnosis) and United Health. Diabetic cataracts, a complication of diabetes, arise when uncontrolled blood sugar levels damage the eye’s lens, leading to clouded vision.
An analysis by the Journal found that UnitedHealth members were approximately 15 times more likely to be diagnosed with this condition compared to the average traditional Medicare patient. Eye doctors consulted by the Journal expressed skepticism about the plausibility of such a high proportion of UnitedHealth patients having this relatively uncommon disease.
From 2019 to 2021, the government paid Medicare Advantage insurers over $700 million for diabetic cataracts, with the majority of diagnoses being added by the insurers themselves.
In another example noted by the Journal, between 2018 and 2021, data indicated that approximately 18,000 Medicare Advantage recipients received insurer-driven HIV diagnoses—the virus responsible for AIDS—yet did not obtain treatment from physicians. These HIV diagnoses result in an additional $3,000 annually in payments to insurers. The quandary is that not 80% plus of these patients were not on antiretroviral medication which is the only treatment for HIV.
The Medicare Advantage insurers claim that the use of home visits is predominantly to identify patient concerns and conditions that can be, if handled proactively, more efficiently (cost) treated, in the least institutional setting (home or outpatient). The home-visit industry has expanded significantly in recent years. Last year, UnitedHealth’s HouseCalls dispatched nurse practitioners to over 2.7 million individuals’ homes. Similarly, CVS’s Signify conducted approximately 2.6 million home visits in 2023.
In the Medicare Advantage system, diagnoses must be documented annually to initiate additional payments. Therefore, individuals who had a prior home visit resulting in extra payments are especially valued.
When patients consent to a visit, companies providing home-visit services dispatch nurse practitioners or, on rarer occasions, doctors or physician assistants. Some of these medical professionals are full-time employees, while others are contractors who receive about $100 or more per visit.
Government contractors audit Medicare Advantage plans and can ultimately recover payments for incorrect diagnoses. Medicare administrators are revising the list of diseases that qualify for higher insurance payments. Heavily utilized diagnoses, such as diabetic cataracts, will receive reduced or no additional payments after the changes are implemented in 2026. However, new conditions like asthma have been added to the list that merits extra payments.
The fundamental problem is that Medicare in many ways, invites this type of fraud. The incentives of higher payment for greater service intensity or more identified disease states, creates the opportunity for “upcoding” – taking advantage of the system by providing care, which is not likely, medically necessary or warranted. Where the rub occurs is in the payment system Medicare uses which presumes, payment is warranted – presumptive, and prospective. Only via whistleblowers or less often, via post claim reviews, is possible fraud identified. This is slow, and time consuming, and given overall claims volumes, like searching for the needle in the haystack.
See my related post from last month https://rhislop3.com/2024/07/11/medicare-fraud-2-75-billion-recovered/