Wall Street Journal Exposes Billion-Dollar Medicare Advantage Fraud
A Wall Street Journal investigation has revealed a substantial problem within the Medicare Advantage system. Between 2018 and 2021, health insurance companies received billions of dollars from Medicare for diagnoses that patients didn't receive treatment for or contradicted their doctors' views. This practice, involving diagnoses made by insurers rather than doctors, could net insurers thousands of dollars per year per patient.
The investigation analyzed 1.6 billion diagnoses using Medicare Advantage data, showing that insurers can add diagnoses to those submitted by patients' own doctors. This is permitted by Medicare to identify conditions that doctors may have overlooked. However, the Journal discovered that insurers were diagnosing conditions that patients weren't treated for, potentially inflating their payments. The companies most affected were UnitedHealth Group, Anthem, Cigna, Humana, and Centene.
The data used in the investigation included information about doctor visits, hospital stays, and prescriptions, but not patient names. The reporters accessed this data through a rare data-use agreement with the federal government, requiring them to submit a hypothesis and describe their intended use, with a nine-month timeline.
The Office of Inspector General for the Department of Health and Human Services has suggested that Medicare stop paying insurers for diagnoses resulting from home nurse visits initiated by insurers. The Congressional Budget Office estimates that eliminating Medicare Advantage payments based on home visit diagnoses would save $124 billion over a decade.
The Wall Street Journal's findings highlight a significant issue within the Medicare Advantage system, where insurers are potentially profiting from diagnoses that patients aren't treated for. This practice could be costing Medicare billions of dollars. Following the investigation, a medical group in Florida self-reported itself for improper payments to UnitedHealth Group. Further action is expected as the issue is reviewed.
