A worrying report says that Medicare Advantage plans got an extra $4.2 billion in 2024 by visiting elderly Medicare beneficiaries at home when they might not have needed them for serious illnesses. The report, which came from the Department of Health and Human Services’ Office of Inspector General, was all about the health risk assessments (HRAs) that were done.
Most of the time, these HRAs are only given to Medicare recipients who have serious health problems that make it hard for them to leave their home. As well as being an important part of the service, they also help Medicare Advantage plans get higher risk-adjusted payments.
For insurance companies, this means getting paid more for their care. Abuse of these HRAs could hurt the program’s overall funds, which is why an investigation was started.
The study didn’t like many insurance companies. It said that UnitedHealthcare got $3.7 billion in risk-adjusted payments last year, making it the biggest beneficiary of the practice. Humana came in second with $1.7 billion, and many of those assessments weren’t needed.
One big problem with the study was that UnitedHealthcare thought it was “a misleading, narrow, and incomplete view of risk adjustment data is being used to draw inaccurate conclusions about the value of in-home care for America’s most vulnerable seniors in Medicare Advantage.”
According to them, the home visits, which usually last between 45 and 60 minutes, were done by “highly trained and board-certified advanced practice clinicians.”
These visits were “among the most comprehensive and thorough assessments of a patient’s health and physical environment available in the health care system,” they said. “They help identify and drive needed follow-up care for the vast majority of the patients with whom we engage.”
Kevin Smith, a spokesman for Humana, said, “HRAs are tools recognized by CMS that help make sure Medicare Advantage members get better care and health outcomes.”
These tests add to and support the care that primary care doctors give, and patients are always sent back to their doctors for follow-up care. We will keep working together with CMS and policymakers to make the HRA more open and accurate, and to make sure the highest standards of care and compliance.
How the report found HRAs affected Medicare Advantage plans
The report says that last year, these home visits were given to 1.7 million Medicare Advantage plan members, but they did not receive any follow-up visits, procedures, tests, or supplies for their diagnoses.
This told the researcher that the visits might not have been right because the beneficiaries did not get any care for what they said were illnesses.
“Because these tools are usually run by Medicare Advantage companies or their third-party vendors instead of enrollees’ own providers, in-home HRAs and HRA-linked chart reviews may be more likely to be abused.” When diagnoses are only found on these kinds of records, it raises concerns about the accuracy of the diagnoses or how well Medicare Advantage patients’ care is being coordinated.
Last year, Medicare paid private insurance companies $7.5 billion for these HRAs and HRA-linked chart reviews. The reason for this is that an HRA and a doctor’s visit have different costs.
The report says that each in-home HRA generates about $1,869 in estimated risk-adjusted payments, while a visit to a doctor’s office or other health care facility earns about $366. “UnitedHealth Group stood out from its peers, especially in its use of in-home HRAs and HRA-linked chart reviews to generate risk-adjusted payments,” the report said of the company.
But they aren’t the only ones. The report says that out of the thousands of Medicare Advantage plan providers, twenty companies were responsible for 80% of the $7.5 billion in risk-adjusted payments. How this problem is solved will set a very important standard for future diagnoses.
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