Audit of UnitedHealth’s Medicare House Calls Shows Little Evidence of Fraud
A recent audit examining UnitedHealth’s home visits for Medicare seniors has revealed minimal support for allegations that the House Calls program leads to unnecessary patient diagnoses, consequently inflating reimbursements from the federal government.
UnitedHealth asserts that these findings justify the continued existence of the House Calls program, which has been scrutinized rigorously by regulatory authorities and lawmakers concerned about potential profiteering within the privatized Medicare system known as Medicare Advantage.
According to an audit report from FTI Consulting, around 96.6% of diagnoses identified during home visits were validated by patient health records. This audit utilized the same vetting methodology as the government, leading to claims that only 3.4% of diagnoses lacked supporting medical information—this error rate is notably lower than that found in the Centers for Medicare & Medicaid Services’ (CMS) prior audits.
UnitedHealth stated that most of the unsupported diagnoses had alternative backing, such as billing records.
The report bolsters UnitedHealth’s defense of the House Calls initiative, where medical professionals evaluate Medicare members’ health in their homes. The company argues that these visits improve access to preventative care for seniors and provide a comprehensive understanding of patient needs, which they believe isn’t always possible in a traditional office setting.
However, detractors contend that these house calls might simply be a method for insurance companies to inflate their reimbursement claims.
In the system of privatized Medicare, compensation to insurers is adjusted based on how extensive a member’s medical conditions are. This scenario presents significant financial motivation for managed care firms to uncover more diagnoses or even exaggerate symptoms in the elderly population.
Critics also express concerns that in-home risk assessments, as utilized in the House Calls program, may encourage insurers to manipulate health records.
A government study in 2024 indicated that major Medicare Advantage (MA) providers, including UnitedHealth, received billions in overpayments through questionable diagnoses linked to health risk assessments. An investigation by the Department of Health and Human Services’ Office of Inspector General revealed that a significant portion of these overpayments stemmed from home visits within programs like House Calls.
For instance, of the $7.5 billion allocated to MA plans from home health evaluations in 2023, UnitedHealth accounted for $3.7 billion. The company has staunchly defended its practices regarding diagnosis documentation submitted to the federal government.
As public opinion continues to deteriorate, and amidst ongoing civil and criminal investigations over Medicare claims, CEO Stephen Hemsley announced plans for an external review of the company’s practices shortly after retaking his role last spring. Initial outcomes from this review were shared in December, highlighting areas needing improvement, yet lacking definitive evidence of the company using its market power for profit enhancement, as critics alleged. UnitedHealth promised to provide more in-depth findings regarding house calls this year.
An FTI Consulting report, which examined a random selection of 200 House Call visits—totaling 494 diagnoses—identified 17 instances where diagnoses lacked medical record backing. UnitedHealth reviewed these cases and generally maintained that most were validated by other types of data. FTI subsequently concurred that 12 of these diagnoses could indeed be substantiated through paid claims.
A spokesperson for UnitedHealth did not provide information on the reimbursement rates for the 17 diagnoses or the broader implications of the 3.4% misdiagnosis rate across its operations. Nevertheless, the company emphasized that these findings indicate a positive trend for the House Calls initiative while acknowledging that there is always more to be done to ensure only valid diagnoses reach CMS.
“These results are significant, yet we are committed to continual improvement,” Hemsley stated. He also confirmed that “critical practices” at UnitedHealth would continue to be subject to independent evaluations, with results shared publicly.
Additionally, the CEO announced the company has successfully implemented all 23 recommendations made by auditors, including FTI Consulting and Analytics Group, establishing an independent team to oversee coding and formalizing a risk assessment monitoring framework.
