A brand new federal watchdog audit is ratcheting up stress on authorities officers to crack down on billions of {dollars} in overcharges linked to Medicare Benefit dwelling visits.
However up to now, the Facilities for Medicare & Medicaid Providers has rejected a suggestion from the Well being and Human Providers Inspector Common to restrict funds stemming from home visits that don’t lead to any medical remedy — a possible pink flag that will sign overcharges.
In late October, the HHS watchdog discovered that the well being plans pocketed $7.5 billion in 2023 from diagnosing well being situations that prompted no medical companies — about $4.2 billion of it by means of well being assessments executed in sufferers’ houses. And courtroom data present that for a decade or extra, CMS officers have did not act on their issues that the house visits waste tax {dollars} and must be restricted.
UnitedHealthcare, the biggest Medicare Benefit contractor, accounted for about two-thirds of the funds tied to dwelling visits and chart critiques, wherein well being plans mine affected person medical information so as to add new diagnoses that may usher in further income, in keeping with the audit.
Assistant Inspector Common Erin Bliss mentioned the well being plans are making billions with out providing any remedy for medical situations they flag through the visits, corresponding to diabetes and main despair.
“Frankly, it must cease,” Bliss mentioned.
CMS, which runs the Medicare program, disagrees.
In a press release to KFF Well being Information by spokesperson Alexx Pons, the company mentioned it “appreciates the OIG’s assessment on this space” and can proceed to review the difficulty.
Nevertheless, CMS disagreed with the OIG’s name to limit use of dwelling well being assessments in computing how a lot to pay well being plans. Individuals on Medicare “ought to have entry to care that’s appropriately offered within the dwelling setting,” CMS wrote in a written response included within the audit report.
“One would assume that CMS would kick its regulatory oversight up a notch or two,” mentioned Richard Lieberman, a Colorado well being information analytics skilled.
“In distinction, CMS seems to be unconcerned and is telling OIG to remain out of their lane,” he mentioned.
UnitedHealthcare spokesperson Heather Soule mentioned in a press release that the OIG had drawn “inaccurate conclusions” within the audit.
The house visits are “among the many most complete and thorough assessments of a affected person’s well being and bodily surroundings obtainable within the healthcare system, serving to to determine and drive wanted follow-on take care of the overwhelming majority of the sufferers with whom we have interaction,” in keeping with the corporate.
No Care Supplied
Authorities spending on Medicare Benefit, which is dominated by UnitedHealthcare and a handful of different medical insurance firms, is anticipated to hit $462 billion this yr.
The trade, whose greater than 33 million members make up over half of individuals eligible for Medicare, argues that most enrollees are happy with the care they obtain and usually pay much less out-of-pocket than these on unique Medicare.
Whether or not Medicare Benefit is an efficient deal for taxpayers is one other matter, largely as a result of many well being plans exaggerate how sick sufferers are to spice up their funds, a number of federal audits and different investigations have proven. Medicare pays the well being plans larger charges for sicker sufferers.
For fiscal yr 2023, CMS recognized $12.7 billion in overpayments linked to diagnoses not supported by sufferers’ medical data.
The OIG audit tied $7.5 billion in funds to well being situations that prompted no remedy, together with critical illnesses corresponding to diabetes, congestive coronary heart failure, and main despair. That implies that the medical situation both didn’t exist or that the well being plan did not deal with it adequately, auditors mentioned.
“These are critical situations. You’d assume you’d see further care throughout that yr,” mentioned Jacqualine Reid, who led the OIG audit group. “We’re asking CMS to step up its oversight.”
Homegrown
The in-home visits have sparked controversy for greater than a decade. A June 2014 media investigation discovered {that a} sharp rise in dwelling visits had inflated Medicare’s prices by billions of {dollars}. The visits, which generally final lower than an hour, are sometimes carried out by nurse practitioners, who don’t deal with the affected person, however go over a guidelines of doable well being situations.
Sabrina Skeldon, a Texas lawyer who advises physicians on billing points, mentioned issues come up when well being plans fail to order needed medical exams to substantiate a analysis made throughout a house go to — and deal with it.
Skeldon famous that The Cigna Group in 2023 paid $172 million to settle a whistleblower lawsuit that alleged its Medicare Benefit plan illegally collected funds for medical diagnoses that have been based mostly solely on in-home assessments.
The OIG audit comes because the Justice Division presses a civil fraud case that accuses UnitedHealth Group of dishonest Medicare out of greater than $2 billion by mining affected person data to churn up diagnoses that boosted income, whereas ignoring proof of overpayments. The corporate denies the allegations.
Court docket filings from the case present CMS officers have been involved years in the past that dwelling visits and chart critiques may needlessly drive up prices.
In April 2014, CMS backed off a proposal to limit their use amid complaints from the trade that it will lose billions of {dollars} because of this. Equally, CMS officers scrapped a proposal to tighten scrutiny on the chart critiques after what one official known as an “uproar” from the trade.
CMS officers additionally had issues that unchecked dwelling visits would possibly have an effect on efforts to get well overpayments by means of billing critiques often called “RADV” audits.
Former CMS official Thomas Hutchinson, who ran the company’s Medicare Plan Cost Group from September 2006 by means of June 2010, testified in a deposition that officers had “heard about varied of us that found out how they may RADV-proof issues by doing in-home visits.”
In a confidential April 2015 slide presentation, CMS officers noticed that well being plans have been “now conducting well being danger assessments in beneficiaries’ houses. One objective of the assessments is to determine situations and create medical data documentation that substantiates diagnoses.”
And an October 2015 CMS memo circulated amongst senior company employees cites “limitations round dwelling visits” among the many doable methods to “strengthen” the RADV audits.
In its assertion to KFF Well being Information, CMS mentioned it was “dedicated” to making sure that diagnoses well being plans submitted for fee have been correct. However the company declined to reply written questions in regards to the influence of dwelling visits on its audit program, which has but to finish critiques of funds courting again so far as 2011.
UnitedHealthcare had the bottom charges of unconfirmed diagnoses amongst 5 massive Medicare Benefit organizations audited in 2011, in keeping with courtroom data.
General, the corporate ended up with underpayments of greater than $261 million for 15 of its plans audited for 2011-2013, courtroom data present. The audit findings for different Medicare Benefit corporations are blacked out in courtroom filings.
CMS audits funds to simply 30 out of greater than 700 contracts a yr. That’s not sufficient to guard tax {dollars}, mentioned Matthew Fiedler, a well being coverage researcher at The Brookings Establishment.
“They need to be auditing 10 instances as many contracts,” he mentioned. “The place we are actually you aren’t prone to get caught.”