UnitedHealth Group stood out from its peers in a new federal watchdog report that questions how Medicare Advantage insurers have used diagnosis data to boost payments from the government program for seniors by billions of dollars.
The Minnetonka-based company was the biggest recipient of the add-on funds based on “questionable” practices for 2023, according to the report this week from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services.
UnitedHealth Group maintains that the OIG report was wrong. The watchdog agency published similar findings three years ago, which UnitedHealth also rejected at the time as misleading and inaccurate.
Medicare Advantage (MA) is a privatized version of the federal health insurance program for seniors, where the government hires health plans to manage care for patients and pays companies more when seniors need more treatment.
The OIG report focused on instances where MA insurers received additional payments from Medicare based on assessments that their patients were sicker than average and at risk for higher-than-average expenses, yet the patients apparently did not receive treatment for conditions documented by those reviews.
Such health assessments can be part of annual wellness visits for seniors, and they’re used to collect information about their health status, risks and daily activities. The watchdog agency took particular aim at assessments performed in patients’ homes, saying they may be more vulnerable to misuse because the assessments often are administered by MA plans themselves or third-party vendors — not patients’ own health care providers.
“Diagnoses reported only on enrollees’ [health risk assessments] and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjustment payments for 2023,” the OIG reported. “Taken together, in-home HRAs and the subset of chart reviews that relied upon in-home HRAs generated an estimated $4.2 billion of the total $7.5 billion in risk-adjustment payments.”
The OIG called on the federal Centers for Medicare and Medicaid Services to impose restrictions on the use of diagnoses reported only on in-home assessments or related chart reviews.