A recent report indicates that a prominent health insurance provider is under scrutiny for allegedly encouraging its staff to make certain diagnoses to secure higher Medicare reimbursements.
This concern has been developing since last summer and involves claims that staff were prompted to document Medicare benefits that would result in higher payments linked to programs for seniors and individuals with disabilities. As highlighted by a news source, investigations by the Department of Justice, FBI, and the Department of Health are looking into patients’ examinations and the protocols used to arrive at specific diagnoses, including the process of sending nurses for home visits.
There hasn’t been a quick response from the Department of Justice regarding this matter.
In a separate statement, the company noted that a healthcare executive, Brian Thompson, was tragically killed outside a hotel in Midtown last year. The firm asserts it “stands firmly behind the integrity of the Medicare Advantage business.”
They also welcomed ongoing reviews of their policies and practices. Previously, members of UnitedHealth Plans had taken issue with a journal that reported they received a higher proportion of certain lucrative diagnoses compared to those enrolled in other Medicare plans.
In response to the situation, UnitedHealth criticized media outlets for conducting what they termed a “sustained campaign against Medicare Advantage,” suggesting it relied on selective data and misunderstanding of how the program functions.
A former employee, Dr. Naysha Isom, mentioned that investigators had inquired about specialized training related to diagnosis creation, along with how patients were contacted to ascertain favorable conditions. She described the focus as largely being on coding—the specific diagnostic codes insurers use to bill Medicare.
Another former physician, Tom Lynn, recounted a conversation with federal prosecutors concerning the company’s documentation practices, including inquiries about training and whether there was pressure to use certain codes. Lynn clarified that they asked about bonuses tied to reviewing potential diagnoses suggested by UnitedHealth.
Moreover, investigators spoke with a nurse who had experience working in UnitedHealth’s HouseCalls unit, which implements software that prompts nurses to visit Medicare enrollees’ homes and record diagnoses.
The company maintains that these diagnostic practices are intended to enhance disease detection. On Wednesday, UnitedHealth announced plans to establish a third-party monitoring and audit system to evaluate these practices.
They also pointed out that a previous long-term investigation by the Department of Justice had not succeeded in obtaining claims of Medicare overpayment.
The report mentioned that doctors and nurses were questioned about several specific diagnoses, including conditions identified with the Quantaflo device, secondary hyperaldosteronism, and arterial disease. Additionally, inquiries were made about a “diagnostic cart” feature within UnitedHealth’s software that displays potential medical issues.
