Medicare Advantage companies are bringing in billions in "questionable" payments found during in-home visits and chart-reviews, HHS' Office of Inspector General claimed in a new audit.
In a report published Oct. 24, the federal watchdog estimated Medicare Advantage companies received $7.5 billion in payments through health risk assessments and chart reviews.
The watchdog wrote that "questionable use" of HRAs is driving up payments to plans.
Medicare Advantage plans conduct HRAs to collect information about enrollee health status. These assessments are sometimes conducted by providers as part of beneficiaries' annual wellness visits, or in enrollees homes. MA plans also conduct chart reviews to find diagnoses that may have been missed by providers during visits.
CMS found 1.7 million Medicare Advantage enrollees with diagnoses from HRAs and chart reviews that were not substantiated by any other visits, procedures or tests in their medical records.
"Diagnoses reported only on an HRA — conducted in any setting — but on no other service records raise questions about whether the diagnoses are valid and whether enrollees got needed care," the OIG wrote in the audit.
MA plans are reimbursed by the federal government based on enrollees' health risk. The policy creates financial incentives for insurers to "misrepresent" enrollees' health status by submitting unsupported diagnoses, the OIG wrote.
Diagnoses reported solely from in-home settings or chart reviews are "especially concerning," the OIG wrote, because these are typically administered by MA plans or vendors, not enrollees' providers.
The top 20 Medicare Advantage companies enroll around 50% of MA beneficiaries, but account for 80% of payments from HRAs and chart reviews, the OIG found.
UnitedHealth Group "stood out from its peers" in its use of in-home visits and chart reviews to generate payments, the OIG wrote.
UnitedHealth Group, the largest Medicare Advantage provider, received $3.7 billion in risk- adjustment payments from HRAs and chart reviews in 2023, the OIG estimated.
In a statement shared with Becker's, a UnitedHealthcare spokesperson said a "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 MA beneficiaries.
"The 45-60 minute in-home visits provided by highly trained and board-certified advanced practice clinicians are among the most comprehensive and thorough assessments of a patient's health and physical environment available in the healthcare system, helping to identify and drive needed follow-on care for the vast majority of the patients with whom we engage," the spokesperson said.
The OIG's audit comes after two investigations by The Wall Street Journal examined the use of chart reviews and HRAs in Medicare Advantage. In an investigation published in July, the Journal estimated MA insurers received $50 billion in payments between 2018 and 2021 for "questionable diagnoses."
Around one-third of these payments came through in-home visits, the Journal reported in a subsequent investigation.
The OIG recommended CMS crack down on the use of in-home HRAs in its audit. The agency recommended the agency exclude diagnoses made during in-home assessments from risk-adjusted payments, or require MA companies to document it took meaningful action to connect the enrollee to treatment for any diagnoses added during the visit.
CMS did not concur with OIG's recommendation to restrict payments for diagnoses found during in-home visits. The agency said there is no definitive method to identify which diagnoses come from in-home health risk assessments.
The OIG also recommended CMS include diagnoses from in-home assessments and chart reviews in its risk-adjustment audits, and examine which diagnoses are most susceptible to misuse.
CMS said it has implemented the recommendation to review diagnoses that may be misused, and is taking steps to exclude or constraint certain diagnoses.