Upcoding: one reason Medicare Advantage companies pay doctors to do home health screenings

Ain early 2023, a planned 2.5 million Americans age 65 and older started using Medicare Advantage plans. Some have made this decision in response to market pressures. This brings total enrollment in Medicare Advantage plans to nearly 31 million.

One of the unexpected “successes” of these plans is an offer by the insurance company sponsoring the plan to send a nurse or physician assistant, usually from a start-up company, to the a person’s house. There is no charge for the visit, and the insurance company may even charge the beneficiary for agreeing to do this. Some companies keep calling to accept the offer.

Before explaining who is interested in these visits, it helps to blur the roles of the players. Health insurance companies do not provide health care. That’s what doctors and groups do. The primary responsibility of insurance companies is to pay bills; they make money by taking more money from their beneficiaries than paying for the medical care they need. Of course, this difference is becoming confusing: some health insurance companies have purchased parts of doctors, and some health systems offer health insurance.


When a person signs up for Medicare Advantage, which comes from a private insurance company rather than the federal one, Medicare does not reimburse providers directly. Instead, a fixed fee is paid to the insurance company, which establishes its own rules for how much and when to pay the company.

Here’s the catch: the amount the insurer collects from Medicare is based on the premium rate rules. The more tests an individual has, the higher their risk, and the higher the risk, the more the insurance company collects from Medicare.


In theory, it seems reasonable. In fact, some Medicare Advantage plans provide tests and intervention policies that result in higher premiums even if these tests actually affect a person’s health or they are being treated for the condition. This is where the free body comes home. Although Medicare already offers them coverage annual health checkup along with their primary care providers, some Medicare Advantage plans encourage home visits to find out about additional insurance policies that allow them to record four co-pays. Higher insurance from Medicare. This is called sign. Although Medicare beneficiaries often get it sick than Medicare Advantage benefits, the use of specialized software, specially trained professionals, and business consultants has created an entire industry dedicated to sports the system.

The rewards for innovation are not trivial. A company may pay as much as $6,700 for an adult with uncomplicated diabetes. But the addition of a single indicator for bleeding disorders — which may or may not affect a health care provider’s treatment decisions — can increase Medicare payments to insurance companies through 45%. And then he just went 5% Medicare Advantage insurers are audited every year, companies that often leave without renewal.

Medical organizations can also use the innovation to increase profits, often among people insured by their own Medicare Advantage plans. Richard Kronick, former director of the federal Agency for Healthcare Research and Quality, is planned the reform would increase Medicare spending by about $20 billion a year over the next decade. Put into perspective, it can be fully supported by that huge salary current federal spending for health research in cancer, heart disease, Alzheimer’s disease, diabetes, mental health, and pediatrics.

How to redirect insurance company money from what Richard Gilfillan and Donald Berwick, former directors of the Centers for Medicare and Medicaid Services, called the “cash machine,” to serve the health care needs of Medicare beneficiaries.

First on the list is developing a scorecard to measure what really matters to people: maintaining functional capacity and quality of life. Many of the quality standards currently used to rate health insurers reflect what health care providers do, such as ordering tests. blood on a regular schedule, rather than whether the benefits of care provided lead to longer or better lives, reduced medical complications, or less. preventable deaths. This is the heart of value-based care: pay health care providers for the outcomes of the patients they serve, not just what they do for their patients.

Due to the Medicare Advantage upcoding damage, new systems are also required to be set up with anti-gaming provisions. Instead of rewarding insurers for adding additional rules to medical records, labels should be read when providers implement those standards effectively. . To combat gambling programs, Medicare will soon unveil a new one audit policy it will reveal when insurance companies use risk management inappropriately. Audits can force companies to pay back tens of millions of dollars. But the industry is ready to fight back, like STAT reportedperhaps by suing the Biden administration to block the tests.

When health insurance premiums grow unchecked, there is less money available for other basic needs, such as food, housing, education, and clean energy, to name a few. Health care in the United States is the largest economy in the history of the world. Unauthorized admissions increase costs without helping patients. This animal must be betrayed. Quitting helps us all.

Robert M. Kaplan is a faculty member at Stanford University’s Clinical Excellence Research Center, a former associate director of the National Institutes of Health, and a former chief scientific officer for the Office of Health. Health Research and Quality. Paul Tang is a primary care physician, faculty member at Stanford’s Clinical Excellence Research Center, and former director of medical information.

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