Home visit companies pushed nurses to run screening tests and add diagnoses during patient visits, which added up to about $15 billion in extra pay from Medicare Advantage between 2019 to 2021, The Wall Street Journal reported Aug. 4.
Each year, insurers send nurses into homes of Medicare beneficiaries to gather health information and identify new diagnoses. The Journal's investigation found that companies push nurses to make diagnoses that they otherwise would not have, and in some cases were unwarranted and based on inaccurate diagnostic tests or misinterpretation of questionnaires. Adding diagnoses and tests have upped the pay for these hourlong visits by $1,818 per visit from 2019 to 2021.
The Journal reviewed Medicare data covering home visits under a research agreement with the federal government. The data did not include patient names but covered details of physician visits, hospital stays, prescriptions and other care.
In July, the Journal found insurers received nearly $50 billion in payments in that span due to diagnoses that were not treated by hospitals or physicians. Diagnoses made during home visits accounted for 30% of that total. Many of the diagnoses were highly questionable or "outright wrong," the Journal said.
For example, more than 700,000 peripheral artery disease diagnoses were made only during home visits — and netted insurers around $1.8 billion in payments in three years. Some patients were diagnosed via a device that gave inaccurate readings, a nurse told the Journal. They used no other standard exam and many patient physicians found the diagnosis was inaccurate.
Some insurers are making more than others on home visits. UnitedHealth, parent company of the largest Medicare insurer, had an average home-visit value of about $2,735 between 2019 and 2021 — nearly three times the average of all other MA insurers. Sixty percent of UnitedHealth home visits generated at least one new diagnosis of a condition no physicians treated. Humana had the second highest rate with 39% of visits having a diagnosis no physician treated, according to the report.
The Medicare Payment Advisory Commission is recommending to reduce the diagnoses that incur extra payments. A CMS spokesperson told the Journal the agency is ramping up audits to verify diagnoses and eliminating some diagnoses from extra payments, including peripheral artery disease.
In Medicare Advantage, private insurers get a lump sum for providing health benefits to about 33.5 million older adults and disabled people in the federal program. The payments go up when patients have certain diseases, giving insurers an incentive to diagnose a range of conditions. The at-home visits can help catch diseases early and ensure patients take their medications properly, insurers told the Journal. The home-visit findings are sent to primary care physicians, who prescribe treatment.
Read the full report here.