Medicare Advantage insurers (managed Medicare) are under growing scrutiny by Medicare's Office of the Inspector General (OIG) as well as the Department of Justice (DOJ) for upcoding and overbilling without the knowledge of plan beneficiaries or their doctors. As a result, the government has overpaid these groups of insurers more the $50 billion dollars, according to an investigation by the Wall Street Journal. You can read the related articles here:
The One-Hour Nurse Visits That Let Insurers Collect $15 Billion From Medicare
Millions of times each year, insurers send nurses into the homes of Medicare recipients to look them over, run tests and ask dozens of questions.
The nurses aren’t there to treat anyone. They are gathering new diagnoses that entitle private Medicare Advantage insurers to collect extra money from the federal government.
A Wall Street Journal investigation of insurer home visits found the companies pushed nurses to run screening tests and add unusual diagnoses, turning the roughly hourlong stops in patients’ homes into an extra $1,818 per visit, on average, from 2019 to 2021. Those payments added up to about $15 billion during that period, according to a Journal analysis of Medicare data. Read more here: Exclusive | The One-Hour Nurse Visits That Let Insurers Collect $15 Billion From Medicare - WSJ
Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated
Gloria Lee was perplexed when the phone calls started coming in from a representative of her Medicare insurer. Could a nurse stop by her Boston home to give her a quick checkup? It was a helpful perk. No cost. In fact, she’d get a $50 gift card.
After several such calls in 2022, Lee agreed. A nurse showed up, checked her over, asked her questions, then diagnosed her with diabetic cataracts.
The finding was good news for Lee’s insurer, a unit of UnitedHealth Group UNH 1.79%increase. Medicare pays insurers more for sicker patients. In the case of someone like Lee with diabetic cataracts, up to about $2,700 more a year at that time.
But the retired accountant doesn’t have diabetes, her own doctor later said, let alone the cloudy vision sometimes caused by the disease.
Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021, including outright wrong ones like Lee’s, a Wall Street Journal analysis of billions of Medicare records found.
The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea.
Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two decades to cover more than half of the 67 million seniors and disabled people on Medicare.
Instead of saving taxpayers' money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said. One reason is that insurers can add diagnoses to ones that patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views.
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