Older adults worry about paying insurance premiums. Government officials have long worried that Medicare, the public insurance plan for those 65 and older, is financially unsustainable.
That’s what makes investigations like one that appeared in The Wall Street Journal and another on STAT this week so disturbing. The Journal reported that insurers regularly send nurses on home visits with the aim of adding new diagnoses to a patient’s file so the insurer can bill Medicare more. Nurses felt many of the diagnoses were unwarranted or based on unreliable screening tests — in particular, a portable device that screens for peripheral artery disease.
That same peripheral artery disease test was profiled by STAT, a publication owned by Boston Globe Media Partners that reports on health, medicine, and scientific discovery, which found that health insurance giant UnitedHealth Group created a sweeping screening program for vascular disease so it could add the diagnosis to patients’ records, then bill Medicare Advantage. Physicians questioned whether there was any health benefit to the screening. The tests have high rates of false positives, leading healthy patients to flood clinics seeking additional testing.
These types of practices are costly. Insurers received nearly $50 billion from Medicare between 2019 and 2021 for diagnoses made by an insurance company of conditions that were never treated by a doctor, the Journal reported in a separate story. STAT said between 2018 and 2021, UnitedHealth received approximately $4 billion for diagnosing artery disease, including valid and questionable claims.
According to the Massachusetts Association of Health Plans, insurers are required under certain state programs that are part of Medicare Advantage to send nurses into patients’ homes to catch illnesses before they escalate, but the association could not say what tests are used. STAT reported that Optum — UnitedHealth’s physician network — has been screening for peripheral artery disease in Massachusetts since November 2017.
Insurers vary in how they use home visits. Amy McHugh, a spokesperson for Blue Cross Blue Shield of Massachusetts, the state’s largest insurer, said Blue Cross uses home visits in a limited way. Only 9 percent of Medicare Advantage patients had home visits in 2023, while other insurers used them three to four times more frequently, McHugh said. “We take a strategic and evidence-based approach to engage members who haven’t had an annual wellness visit or don’t have a PCP, who have critical gaps in care, and whose health history indicates a need for care management,” McHugh said.
Home health providers refer patients to follow-up care and social services, and assessments are reviewed for accuracy and shared with their primary care doctor if they have one. Signify Health, which is contracted with Blue Cross Blue Shield to do the home visits, only does screening for peripheral artery disease in a targeted way, on 4 percent of patients, McHugh said.
The practice of using home visit diagnoses to enhance billing is known to federal regulators. A March 2024 report to Congress by the Medicare Payment Advisory Commission found that “health risk assessments,” conducted during annual home visits, often rely on patients’ self-reporting of medical conditions, which can result in inaccurate diagnoses. In 2022, the report found that diagnostic coding based solely on a health risk assessment accounted for $13 billion in payments to Medicare Advantage plans. It recommended that Medicare not increase payments solely based on home visit diagnoses.
The US Department of Health and Human Service’s Office of Inspector General noted in a 2020 report that because Medicare pays higher rates for sicker patients, insurers have incentives to make patients appear sicker. The inspector general suggested that health risk assessments are used by insurers not to improve care quality but to drive up billing. The office recommended the Centers for Medicare and Medicaid Services better oversee organizations conducting health assessments and “reassess the risks and benefits” of allowing diagnoses made during in-home health risk assessments to increase payments.
Medicare this year cracked down on excessive diagnoses of peripheral artery disease, removing a code that let insurers bill for patients who weren’t experiencing symptoms. But that’s only the tip of the problem of “upcoding.” A separate STAT investigation detailed the pressure UnitedHealth puts on doctors to code patients for as many illnesses as possible. The Medicare Payment Advisory Commission criticized the practice of chart reviews, where an insurer reviews a patient’s medical record to identify diagnoses a doctor never reported.
The Centers for Medicare and Medicaid Services told The Wall Street Journal it is ramping up audits to verify diagnoses and eliminating some diagnoses from qualifying for extra payments. CMS should continue addressing this issue by listening to its advisers and ending reimbursements for diagnoses based solely on dubious at-home assessments.
Home visits by nurses can be valuable if they keep patients healthier by monitoring a patient’s medication or catching illness before it escalates. But hiring nurses whose job is to make a patient appear sicker than they are just wastes taxpayer money.
Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.
