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]

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@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... 

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@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. 

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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]

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@Tonster521 wrote:

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

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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]

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@Tonster521 wrote:

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

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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.

[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.