Medicare Advantage plans earned $4.2 billion in additional benefits last year by making home visits to older adults who may not be receiving treatment for serious health problems. new government report I found it.
The report, issued by the Department of Health and Human Services' Office of Inspector General, raises concerns about so-called health risk assessments (HRAs), or home visits to diagnose serious health problems in Medicare enrollees. .
Because older adults with serious health problems may receive higher risk-adjusted payments for Medicare Advantage plans, authorities are asking whether these HRAs are being abused at a cost to taxpayers. I was thinking of deciding what to do. almost half Of the 66 million seniors enrolled in Medicare, some also enroll in Medicare Advantage plans offered by private insurers such as UnitedHealthcare and Humana.
UnitedHealthcare collected $3.7 billion in risk-adjusted payments last year, making it the medical practice's largest beneficiary, followed by Humana Inc. with $1.7 billion, according to the analysis.
UnitedHealthcare disputed the study.
In an email to CBS MoneyWatch, the company said, “Medicare Advantage uses misleading risk-adjusted data to draw inaccurate conclusions about the value of home care for America's most vulnerable seniors.” , a narrow and incomplete view is being taken advantage of.”
Home visits typically last 45 to 60 minutes and are delivered by highly trained, board-certified, highly specialized clinicians who are familiar with the patient's health and physical environment available in the health system. is one of the most comprehensive and thorough assessments of the world, identifying and driving the subsequent care needed for the vast majority of patients we work with,” the company added.
“The HRA is a tool recognized by CMS to help Medicare Advantage members receive better care and health outcomes,” Humana spokesperson Kevin Smith said in an email. “The assessment complements and supports the care provided by primary care physicians, and patients are always referred to their primary care physician.” Doctor for follow-up. ”
Smith added, “We continue to work closely with CMS and policymakers to improve HRA transparency and accuracy standards and ensure the highest standards of care and compliance.”
The report raises concerns about how Medicare Advantage (MA) plans use HRAs and the amount of taxpayer spending associated with these home visits. Approximately 1.7 million people enrolled in Medicare Advantage plans received such home visits last year, but they did not receive supplies for follow-up visits, treatments, tests, or diagnoses. This suggests that the payment may have been “inappropriate” or that the registrant may not have paid. They can get the care they need, the report concludes.
In addition to potential overpayments for HRAs, Medicare Advantage plans may also be receiving billions more from so-called HRA-related chart reviews. These occur when a Medicare Advantage company later reviews a senior's medical records looking for diagnoses that the health care provider may not have submitted or submitted incorrectly.
“In-home HRAs and HRA-linked chart reviews may be susceptible to abuse as these tools are often managed by the MA firm or its third-party vendor rather than the enrollee’s own provider.” the report points out. “Diagnoses reported only in these types of records raise concerns about the validity of the diagnosis and coordination of care for master's program enrollees.”
According to the report, Medicare paid approximately $7.5 billion last year to private insurers operating Medicare Advantage plans for diagnoses reported through both HRAs and HRA-related medical record reviews.
$1,869 Home visit
Each household's HRA generates an estimated risk-adjusted payment of approximately $1,869, according to the report. By comparison, Medicare Advantage plans pay approximately $365 when patients visit a doctor's office or other health care facility.
The analysis found that of the $7.5 billion in risk-adjusted payments for Medicare Advantage plans, $5.6 billion was caused by 13 health conditions, and vascular disease was associated with approximately $1 billion of these payments. was found to be the most common diagnosis.
However, the analysis found that home diagnosis is not necessarily backed up by a visit to a doctor or medical facility. For example, Medicare Advantage companies diagnosed “secondary hyperaldosteronism,” an adrenal gland problem, in 74 percent of enrollees. This diagnosis was made through a home visit leading to payment or review of medical records associated with the HRA.
Only 3% of enrollees received this diagnosis through a clinic or other health facility visit.
The analysis found that 20 Medicare Advantage companies generated about 80% of the $7.5 billion in risk-adjusted payments. The report faulted UnitedHealth Group, saying the company “stands out from its peers, particularly in its use of in-home HRAs and HRA-related medical record reviews to generate risk-adjusted payments.” .
