Insurer Agrees in making Medicare Advantage Changes

[GailL1]

Humana, the second-biggest Medicare insurer, has told congressional staffers that it will support moves that would curtail billing practices worth billions in extra payments to the industry, according to staffers and a document viewed by The Wall Street Journal. The stance by a leader in the Medicare Advantage business—in which insurers offer privately run Medicare plans—represents an important development in a growing debate over how the companies are paid in the $460 billion program.

This is from an article in the WSJ to which I do not have free access but am taking the same info from Reuters which has some of the same info - read either to which you have access.

Now what is the best way to get all the insurers onboard?  Support - just saying.

WSJ 06/05/2025 - Humana to Back Curbs to Medicare Advantage Billing Practices

(Healthcare)

Reuters 06/05/2025 - Humana to back curbs to Medicare Advantage billing practices, WSJ reports  (Business)

[TRL1111]

MSN.com often reprints Wall Street Journal stories, without a paywall. Try this:

msn.com/en-us/money/companies/humana-to-back-curbs-to-medicare-advantage-billing-practices/ar-AA1G8n... 

[Tonster521]

@GailL1, I am not sure if the insurance companies that offer Medicare Advantage are being paid a windfall in addition to the standard headcount payment. I suspect the payment is based on the underlying diagnosis. As you know, many folks do not visit a physician for every medical issue that may surface from time to time. Some issues such as high blood pressure, high sugar, high cholesterol, bad knees, bad hips, overweight, substance abuse,etc. may go without treatment for years until the issues become acute and immediate attention is needed asap. As a concept, managing medical care makes sense; and, if the patient follows the medical advice, a bigger problem may be avoided. However, when an insurance company uses an assessment/evaluation procedure to simply gain additional headcount compensation, that is gaming the system. It would be interesting to know if assessments/evaluations do reduce acute and possibly catastrophic medical episodes. So, the question is whether Humana will be "carte blanche" eliminating assessments/evaluations from their procedures or just eliminating gaming the system in cases wherein the evidence is questionable. 

[TRL1111]

---

@Tonster521 wrote:

It would be interesting to know if assessments/evaluations do reduce acute and possibly catastrophic medical episodes.

Certainly not in this case:  "For instance, more than 66,000 Medicare Advantage patients were diagnosed by their insurers with diabetic cataracts even though they had already had surgeries that cured the condition, making it anatomically impossible for them to have it."

I would encourage you to read the Wall Street Journal story about the investigation their reporters did into these payments:  

msn.com/en-us/money/other/how-health-insurers-racked-up-billions-in-extra-payments-from-medicare-adv... 

---

@Tonster521 wrote:

So, the question is whether Humana will be "carte blanche" eliminating assessments/evaluations from their procedures or just eliminating gaming the system in cases wherein the evidence is questionable. 

---

You should read the current WSJ article, too.  What Humana is offering is proposals for reform that will apply to everyone.  They never said anything about changing their own policies.

And FWIW, the article said this:  "UnitedHealth on average gained $2,735 in payments per home visit. Humana landed $1,525."

[Tonster521]

@TRL1111 I have read the link that you provided and, at first, are lead to believe that there is some "gaming the system" taking place. However, I suspect large providers of MA Plans such as UHC and Humana are not going to risk losing lucrative contracts/business trying to increase Medicare payments by small amounts. With regard to medical terminology which I think is called ICD (International Classification of Diseases) and the corresponding codes, I do not know if a providers changes the code over time. For example, I obtain a medical physical every year and my glucose was creeping up in the range that is acceptable. Although not a diabetic, my physician suggested a diabetic eye exam from an ophthalmologist. As you know, there is good news and not so good news. I did not have diabetes or vision related issues related to diabetes, but had cataracts. I was connecting some vision issues that I was experiencing with cheap glasses that I bought from a popular vision franchise. Anyway, the doctor called it "age related" and still uses that diagnosis for follow up visits even though I had cataract surgery on both eyes. So, I do not know if or when a diagnosis code changes. Once again, think hypertension (high blood pressure) that is controlled by medication and an appropriate lifestyle ( i.e., stop smoking, diet, exercise, etc.). Follow up visits are probably coded hypertension even though a person's blood pressure is in range. 

At any rate, Medicare payments to MA Plans are complicated. I will try to link an article or two that provides some of the complex calculations that are utilized by Medicare. https://www.kff.org/medicare/issue-brief/higher-and-faster-growing-spending-per-medicare-advantage-e... Another article that is informative concerns Quality Bonus Payments https://www.kff.org/medicare/issue-brief/medicare-advantage-quality-bonus-payments-will-total-at-lea... and lastly https://www.kff.org/medicare/issue-brief/what-to-know-about-medicare-spending-and-financing/#:~:text...). Hopefully, I copied and pasted the articles correctly. It will help folks to understand why MA Plans are paid the way they are paid. There are statistics, numbers, other data that require concentration. I read more articles, but thought the three that I linked will provide the concepts on how MA Plans are paid. If folks grasp anything from the info/concepts, they should understand that Medicare is not just issuing increased payments to MA Plans. So, it would be interesting to know what Humana is proposing that would change the current methodology; and, hopefully, keep a MA Plan viable and a going concern. Maybe, Humana who is second in MA Plans behind UHC believes some of the other smaller MA Plan insurers will fall by the wayside and Humana may be able to obtain some of that business. Medicine is a competitive business.

[TRL1111]

---

@Tonster521 wrote:

I do not know if a providers changes the code over time. 

---

Doesn't matter.  The investigation was into diagnoses generated by the insurance company pursuant to home health visits.  A person who is not a patient's doctor (and not even a doctor at all) is paid by the Advantage plan to do a home health visit.  Any diagnoses that person makes are used to "upcode" the patient, with the result (goal) that the Advantage company gets more money from the government on behalf of that patient.  The patient's doctor doesn't necessarily even find out about the diagnosis, the patient doesn't necessarily receive treatment, and in some cases, as I noted, the diagnosis is apparently anatomically impossible.

[Tonster521]

@TRL1111 Are you sure you have the facts concerning home health visits accurate? First, I am not aware of any doctor that does home visits. I am sure there may be a few that do, but many do not. During the Covid years, some doctors did Tele Medical phone calls, but again, not every doctor did. Having doctors do "windshield work" driving from house to house is cost prohibitive. So, I am not sure of the credentials of a person who does home health visits. However, I am aware of Advanced Practice Registered Nurses and Registered Nurses who do house calls. I suspect the person that does a home health visit is required to have a medical background and perhaps knowledge of taking vitals as well as appropriate questions to ask. I do not believe it is an administrative business person with a mission to "upcode " every patient. When I have a doctor visit, I spend about an equal amount of time with the RN doing vitals (i.e., height, weight, blood pressure, pulse, oxygen level, mental evaluation, other medical problems, etc.) and the doctor evaluating the results as well as a physical exam. I have never had a home health visit. So, I do not know the procedure or the credentials of a person that does a home health evaluation. I do know that my vitals as well as any info I provide the RN is recorded in my record for my doctor to review. Are you sure the home health visit is not recording any pertinent medical info into a person's medical record? I doubt that this is happening. The possibility of litigation for a missed diagnosis is malpractice. I do not believe an insurance company and/or doctor is willing to risk such negligence for a few dollars more from Medicare. I do not know of any doctor or organization or insurance company that would hide pertinent information in our litigious world.

[TRL1111]

---

@Tonster521 wrote:

@TRL1111Are you sure you have the facts concerning home health visits accurate? 

---

Yes.  

To be honest, I can't believe that someone could read the WSJ article about its investigation and conclude that upcoding by Advantage plans is not going on. 

And I never said an administrative business person conducts the home visit.  But it is definitely not the person's doctor, and in fact the person and the doctor may not even know about the insurance company-generated diagnosis.  Read the article again about how many people are given these diagnoses and yet never receive treatment for that condition.

[Tonster521]

@TRL1111I have to ask you again, are you sure you have the facts concerning home health visits accurate? 

I have read the article by Christopher Weaver (CW) - WSJ dated January 2, 2025 several times (via the MSN access) and it is abundantly clear in the second paragraph of the first bullet point that CW states that Medicare allows insurers to tack on additional diagnoses after reviewing medical charts and sending their own nurses to visit patients at home. The key words are "Medicare allows" , "reviewing medical charts", and "and sending their own nurses". Your post dated June 12, 2025 states that a person who is not a patient's doctor (and not even a doctor at all) is paid by the Advantage plan to do a home health visit. Why did you not indicate a Nurse when CW stated nurses in the WSJ article? This is why I asked if you have the facts accurate. I am aware that Advanced Practice Registered Nurses (APRN) and Registered Nurses (RN) do Home Health Visits. Many doctors do not do home visits and many no longer do Tele Medical phone visits. Since you indicated "a person" who is not a doctor and did not acknowledge a nurse, who were you referring to? As I mentioned, I do not believe it is an administrative business person because CW clearly indicated a nurse. 

You mention that the person and (his/her) doctor may not even know about the insurance company diagnosis. How do you know the medical info obtained by an APRN or RN is not being recorded in a patient's medical record? Are there no records of an APRN or RN visit in the patient's medical record? This is the only way I believe a doctor would not know about a diagnosis obtained in a home health visit. Or the doctor elects not to review a patient's medical records which has been known to happen. How do you know that a patient never receives treatment for a diagnosis or condition that may be obtained in a Home Health Visit or the doctor's office. I would think that CW or the WSJ would need to obtain the patient's authorization to release such confidential medical info.

Lastly, I included links to articles from KFF that address the Medicare Advantage Plans including the Quality Bonus provisions which is approved by Medicare. FYI, KFF goes into greater detail and arrives at lower amounts than CW - WSJ.

[TRL1111]

---

@Tonster521 wrote:

@TRL1111I have to ask you again, are you sure you have the facts concerning home health visits accurate? 

Yes.

---

@Tonster521 wrote:

I have read the article by Christopher Weaver (CW) - WSJ dated January 2, 2025 several times (via the MSN access) and it is abundantly clear in the second paragraph of the first bullet point that CW states that...

---

Are you reading the full article?  I wonder, because it doesn't have bullet points.  Try this link for the full article (dated July 8, 2024); it worked on all three of my browsers without encountering a paywall, so hopefully it will work for you:

wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d?mod=RSSMSN 

---

@Tonster521 wrote:

How do you know that a patient never receives treatment for a diagnosis or condition that may be obtained in a Home Health Visit or the doctor's office. I would think that CW or the WSJ would need to obtain the patient's authorization to release such confidential medical info.

---

Here's a link where the WSJ explains its reporters' methodology in examining the records:

wsj.com/health/healthcare/medicare-advantage-data-methodology-8e54a67c?page=1&mod=article_relatedinl... 

But perhaps most telling is that Humana is on board with curtailing insurer-driven diagnosis practices you're trying to defend.  Well, as long as the others are required to curtail it, too.  

[Tonster521]

 @TRL1111 The only link that I was able to open was the one you included in your June 9, 2025 post (via MSN How health insurers rack up billiobs in extra payments from Medicare Advantage). The other previous links were subject to the WSJ pay wall. FYI, today, I am not able to access that January 2, 2025 article via MSN. It is now subject to the WSJ pay wall. However, I was able to access thw WSJ links that you included in your June 19, 2025 post. Those links (July 2024) are informing readers of essentially the same information. I will state that the $50 billion figure that the WSJ may be an accurate amount for the period 2019 to 2021. However, I doubt that the second part of their declaration; namely, even though no doctor ever treated the disease is accurate. Just for analysis, use $250 for the cost of a doctor visit. There would be 8,250,825 office visits over that period of time wherein a doctor did not treat a diagnosis that, I believe, is part of a person's medical record. I know in my case, every medical item that I have mentioned to the RN and Doctors that I have seen, are noted in my medical record. I think if medical information is being withheld by the APRN and/or RN and doctors, that is a bigger problem to deal with. 

I believe managing medical care is an effective approach to managing medical costs. Addressing a medical problem before it is catastrophic, makes perfect sense. How do you find out about medical issues? Generally, an examination by an appropriate medical person is required. In my opinion, this can be done in a hospital, doctor's office (clinic) or at home. 

With regard to gaming the procedures established by Medicare and the insurers, violations need to be addressed. To state that the procedure is a scam and everyone is up-coded just for a few dollars more is not an accurate analysis. For example, the SSA informs us that we contribute approximately 25% of the cost fpr Part B. Using $185/month (for most of us), Part B costs $740/month. That means the Federal Government is covering the other $555/month. If a person leaves Part B coverage and elects an HMO, PPO, POS, or whatever other acronym is available, how much of that $555/month should be allocated to one of the three letter Plans? Should it be a flat rate? A variable rate? If variable, what criteria should the SSA or CMS use? I think a diagnosis related criteria is fair. As you know, most folks have medical issues that come with age. So, those folks should be allocated an amount that is greater than a flat rate for a healthy individual. The CMS witnessed the success that the private sector obtained with managed care. So, as I experienced, the SSA/CMS started promoting a managed care approach in the late 1970's with HMOs being the leading approach. FYI, I worked in manufacturing and at the company's California locations, we could not give an indemnity plan away for free. Employees and retirees wanted Kaiser Permanente 100%. It was the same case in CT. Nobody wanted an indemnity plan. However, the Midwest locations were just the opposite, electing indemnity over HMOs. However, in the 1990's all indemnity plans were amended to a managed care approach and the results were positive. One feature that paid for itself and then some was a no cost physical. It was during that examination that a doctor or physician assistant discovered medical issues that could become bigger issues (i.e., hypertension,diabetes,smoking, etc.). Obtaining medical info and addressing a diagnosis before it becomes an acute hospital confinement is clever. However, there are always folks that do not follow a healthy lifestyle, do not take medications, self medicate, or just get dealt a bad hand in the game of life/health. Managing medical care is a challenge in those cases. However, to stop a procedure for managing care may end up with greater costs.

[TRL1111]

---

@Tonster521 wrote:

 I think a diagnosis related criteria is fair.

---

Nobody has said it isn't.

It's insurer-driven diagnoses that are the problem, and Humana is agreeing to curtail those.  You have to wonder why, if they're as wonderful as you describe them.

[Tonster521]

 @TRL1111 You need to reread the replies that I posted. I did not mention Humana is wonderful. I asked if Humana was "carte blanche" eliminating evaluations/assessments from their procedures or just eliminating gaming the system in cases were the evidence is questionable (June 9, 2025 reply to GaiL1). As I mentioned in my replies, the evaluation/assessment procedure is the established procedure by CMS and MA Plans. What other procedure would you suggest as an alternative? How would you fund an MA Plan? If you suggest a flat amount, just about every MA Plan would go "belly up" or fail. How would you address Adverse Risk? It should be abundantly clear that all Medicare benefits are funded by Medicare Part A payroll taxes and Parts B and D by government subsidies (approximately 75% of cost) and Monthly contributions from folks that elect such coverage(s) (approximately 25% of cost). The 25% of cost is called a monthly premium. The 75% may be considered a "gift" from the Federal Government, but whatever name you use, it is a welfare benefit. It is not based on income (i.e.,Medicaid, etc.) and is available to all that elect Part B. So, how much of that Part B money should be paid to a MA Plan? Remember many folks over age 65 have pre existing conditions as well as folks under age 65 who are disabled. 

I believe an evaluation/assessment is a fair approach. As the WSJ pointed out, the CMS uses audit procedures to review Medicare payments to MA Plans. There have been no widespread abuse of gaming the system. Although I am sure there are cases that are questionable and could be or should be challenged by the CMS auditors, those cases do not amount to $50 Billion as the WSJ indicated. Here is another numerical approach to think about. If $50 Billion is the correct amount, divide that by 25 Million covered by MA Plans. That amount is $2,000 on average. As you know, $2,000 is not nearly enough to cover medical expenses. For comparison, as noted above, Part B is subsidized over $6,000 on average. Do you think Humana may be asking for more money? What makes you think Humana will be asking for less?

[TRL1111]

---

---

It's insurer-driven diagnoses that are the problem.  

"Insurers can add diagnoses to ones that patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views."

"Insurers added diabetic cataract diagnoses to 148 patients treated by Dr. Howard Chen, an ophthalmologist in Goodyear, Ariz. He said he saw at most one or two such cases a year."

[GailL1]

@TRL1111 

Yep that is right - and now it has taken all this while for CMS to get wise to this strategy.  LOL

If Humana is on board and I did read somewhere that UHC is also then I think perhaps we might be at the beginning of a revelation to this sort of upcoding.  I don’t know how much the other bigger insurers are into doing this.  

They will still be able to determine higher risk patients  but it will have to relate to a medical condition or provider notes to verify it - no more home visit upcoding if CMS can get the rules changed.  Sometimes I think things are a done deal and then something happens in Government to change it - so it just warrants following on CMS Press Releases.    

BTW, thanks for the msn link to the WSJ article.