In recent years, Medicare Advantage (MA) programs have faced scrutiny for payments tied to non-medical home visits. These visits, typically brief and performed by nurse practitioners, aim to assess the health of Medicare beneficiaries at home, but critics argue they lead to inflated diagnoses and unnecessary government expenses.
This practice has drawn attention from the Health and Human Services (HHS) Inspector General, who recommended limiting payments related to these home visits. However, the Centers for Medicare & Medicaid Services (CMS) rejected the proposal, leading to an ongoing debate about the role and impact of these home health assessments.
The HHS Inspector General’s audit revealed that in 2023 alone, MA programs billed Medicare $7.5 billion for diagnoses made during home visits and medical record reviews that didn’t require any follow-up treatment. This includes approximately $4.2 billion paid for diagnoses documented without further treatment. Another $5.2 billion was marked as questionable, bringing the total questionable payments to $12.7 billion. UnitedHealthcare, the largest MA provider, accounted for two-thirds of these claims, raising concerns about industry practices.
Key Takeaways
Medicare Advantage home visits have been criticized for potential overcharging, with billions of dollars in questionable payments tied to non-medical home visits.
- Critics argue that Medicare Advantage payment structure is unsustainable due to billions being spent on services lacking real medical benefits.
- The Centers for Medicare & Medicaid Services (CMS) has rejected proposals to limit payments related to home visits, leading to ongoing debate about the role and impact of these assessments.
- Health experts and auditors question whether in-home health assessments provide substantial value, with some arguing that they merely document conditions rather than managing them.
Health experts and auditors concerns
Health experts and government auditors question whether the MA payment structure is sustainable, especially given the billions being spent on services that critics say lack real medical benefits. Jacqualine Reid, head of the audit team from the Office of the Inspector General (OIG), expressed her surprise that so many diagnoses, some severe, were not followed by treatment. For her team, this suggests a disconnect between assessments and actual patient care.
These are serious conditions. You would think you would see additional care during that year
Jacqualine Reid, who led the OIG audit team
Research reveals that home visits are not only brief—usually less than an hour—but also costly. A 2014 study indicated that these home visits led to a noticeable rise in Medicare costs, with little evidence that they improved patient care. Critics argue that without appropriate follow-up or treatment, these visits merely document conditions rather than managing them, and taxpayers are left covering the bill for services that may not provide substantial value.
Industry pushback and revenue concerns
The MA industry, including UnitedHealthcare, has strongly opposed attempts to regulate home visits. Many insurers claim these assessments provide essential insights into a patient’s health, allowing providers to detect potential issues in the home environment.
According to UnitedHealthcare’s spokesperson, Heather Soule, these assessments offer some of the most thorough evaluations available, helping both providers and patients. Insurers also argue that limiting payments for home visits could harm revenue, potentially affecting patients’ access to these in-home services.
CMS itself sided with the MA industry, asserting that Medicare beneficiaries should have access to care where it is convenient, including at home. They argue that in-home assessments help ensure that patients receive care tailored to their needs and living conditions. Yet, health policy analysts point out that these visits may not always result in better outcomes, as insurers might document diagnoses to increase compensation rather than to direct patient care.
Legal and policy impacts of inflated diagnoses
This issue has also led to legal action. The Department of Justice has filed a civil fraud lawsuit against UnitedHealth Group, accusing it of manipulating patient records to inflate diagnoses and increase revenue by over $2 billion. According to court documents, CMS officials were aware of this practice for years but had taken little action to curtail it.
Former CMS official Thomas Hutchinson mentioned that some insurers had even figured out how to work around CMS’s Risk Adjustment Data Validation (RADV) audits by strategically using home visits.
The lawsuit brings up a critical concern: the lack of rigorous CMS oversight may allow MA providers to exploit in-home assessments for profit rather than genuine patient care. Despite years of warnings, CMS has yet to address the underlying issues with its review process, leaving taxpayers and Medicare beneficiaries vulnerable to potential financial misuse.
Calls for reform and audits
Health policy experts are pushing for significant reforms in how Medicare Advantage plans are audited. Matthew Fiedler, a scholar from The Brookings Institution, emphasized that CMS’s current auditing process only covers a small fraction of the over 700 contracts it holds with MA providers each year. He argues that without comprehensive auditing, CMS cannot prevent overcharges or protect taxpayer dollars effectively.
CMS’s RADV audits, meant to identify improper payments, review fewer than 30 contracts annually out of the hundreds in the program. Many believe this limited scope fails to ensure that MA payments align with documented patient needs. Critics argue that CMS should increase both the number and scope of its audits to ensure taxpayer money is used responsibly.
The debate on patient care impact
The impact of these home visits on seniors and elderly patients remains a subject of debate. Proponents argue that in-home health assessments offer valuable care for those who may struggle to reach medical facilities. For these individuals, in-home assessments can provide a convenient way to monitor their health. However, critics contend that these visits may not be essential, often leading to over-diagnosis or adding minimal medical value.
To supporters, in-home assessments make sense for elderly patients who prefer the comfort of their homes, especially if they face mobility challenges. On the other hand, skeptics argue that these visits often lack meaningful follow-up and result primarily in increased MA payouts rather than improved health outcomes. The evidence for real patient benefits remains unclear, making this issue even more contentious.
Challenges for seniors with limited mobility
For many elderly Americans, particularly those with mobility limitations, getting to a healthcare provider can be challenging. In-home health assessments, therefore, offer a valuable alternative by providing some level of care within the comfort of their homes. These visits are marketed as a way to address health needs without requiring travel to a doctor’s office, which is especially beneficial for seniors facing transportation or physical mobility issues.
However, critics argue that these visits may fall short of meeting the complex health needs that many elderly patients have. Since these assessments are typically short and often conducted by nurse practitioners rather than doctors, they may not provide comprehensive medical evaluations. Seniors might not receive sufficient follow-up care, leaving their underlying conditions unaddressed and their overall health potentially neglected.
Financial impact on Medicare and taxpayers
Medicare Advantage spending has skyrocketed, with government expenditures on the program expected to exceed $462 billion this year. Proponents of Medicare Advantage argue that it saves seniors money out-of-pocket while still delivering quality care. Yet, the significant increase in government spending linked to in-home assessments raises questions about the program’s financial sustainability.
Medicare Advantage plans utilize prior authorization to shift patients off their balance sheet and towards taxpayers. This practice cost $6B to private taxpayers in order to profit shareholders of the largest insurers.
We need reform of the Medicare Advantage programs and to… pic.twitter.com/cqNwv5uC89
— Adam Bruggeman, MD (@DrBruggeman) November 12, 2024
For taxpayers, the rapid rise in MA payments tied to these in-home diagnoses has been cause for concern. There is evidence that some health plans may be artificially inflating patients’ diagnoses to secure higher compensation from Medicare, which points to a need for more vigilant oversight to prevent potential abuse. Analysts warn that, without careful reforms, MA could become a growing drain on federal resources without delivering proportional benefits to beneficiaries.
Balancing care and costs
The ongoing debate over Medicare Advantage home visits highlights the complex balancing act between providing accessible care and maintaining financial accountability. Insurers and policymakers must navigate a fine line to ensure that taxpayer funds support necessary medical care without enabling potential abuses. In this high-stakes environment, calls for enhanced oversight are growing louder, and reform advocates stress that protecting both patients and tax dollars is essential.
Ultimately, this issue impacts not just Medicare beneficiaries but the broader healthcare system. As more elderly Americans rely on Medicare Advantage, ensuring that funds are used effectively will become increasingly critical. For policymakers, the challenge is to create a system that values both patient care and accountability, securing the future of Medicare Advantage as a program that genuinely benefits those it is meant to serve.
