Of the 65 million people who get healthcare coverage through Medicare, approximately 30 million access their coverage through Medicare Advantage plans (MA). Most people who have a MA plan say they chose Medicare Advantage because it provides coverage for dental, vision, hearing and prescription drugs, all services Original Medicare doesn’t cover.
If you’re one of those who has a Medicare Advantage plan, you’ve probably received a phone call from the insurance company offering you a home health assessment. They say the assessment is an additional feature of your MA plan. One Medicare Advantage website says the home health visit:
Brings flexible, comprehensive and personalized health evaluations right to your front door. Our experienced clinicians, backed by innovative technology, visit millions of health plan members nationwide yearly to improve their lives and health outcomes. In just one easy appointment you receive a detailed picture of your health, with the time to get your questions answered.
During the visit, a clinician under contract with the insurance company performs a physical examination, reviews your medical history, goes over your medications, and performs diagnostic and preventative screenings. Sometime later you receive a visit report and care plan that’s also shared with your doctor. And, it’s all done at no cost to you. Sounds great, right? But is the purpose of the assessment for your benefit or the insurance company?
According to the U.S. Office of the Inspector General, in 2023 Medicare Advantage plans used in-home health risk assessments and chart reviews to justify an estimated $7.5 billion in enhanced payments from the government. According to the Medicare Rights Center, a national, nonprofit consumer service organization focused on ensuring access to affordable healthcare for older adults and people with disabilities, that means the government could pay out more than $1 trillion additional dollars over the next ten years.
To ensure equal access to Medicare Advantage plans for all patients, the government gives private insurers additional money known as risk-adjusted payments when they enroll someone who has more health issues. These higher payments are meant to help offset the higher costs of insuring someone who’s not healthy.
But some Medicare Advantage plans have found a way to make enrollees look sicker than they really are using a process called upcoding.
With upcoding, the provider submits a billing code for a more serious and more expensive diagnosis based solely on information collected through a health risk assessment (HRA) which could be either an in-home visit or a review of a medical chart. By entering diagnoses through a health risk assessment, insurers can pocket the increased risk-adjusted payments without incurring any additional costs for patient care.
The Office of the Inspector General found that that approximately 1.7 million Medicare Advantage enrollees have records showing an up-coded diagnosis but no care related to the health condition. The Summary of Findings from the OIG says:
“The lack of any other follow-up visits, procedures, tests, or supplies for these diagnoses … raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.”
The OIG made three recommendations for solving the misuse of health risk assessments for upcoding:
- Imposing restrictions on their use
- Conducting audits to validate a diagnosis
- Determining whether certain health conditions are most vulnerable to misuse by Medicare Advantage providers
When asked about the report, the Centers for Medicare & Medicaid Services agreed with only the third suggestion.
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