Exclusive | Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated

🌈 Abstract

The article discusses the issue of Medicare Advantage insurers making questionable diagnoses that trigger extra taxpayer-funded payments, including outright wrong ones. It examines how private insurers involved in the government's Medicare Advantage program have made hundreds of thousands of such diagnoses from 2018 to 2021, leading to billions in extra payments from Medicare.

🙋 Q&A

[01] Medicare Advantage Insurers' Questionable Diagnoses

1. What are some examples of the questionable diagnoses made by Medicare Advantage insurers?

• The insurers made diagnoses for potentially deadly illnesses like AIDS, for which patients received no subsequent care.
• They also made diagnoses for conditions people couldn't possibly have, such as diabetic cataracts for patients who did not have diabetes.
• In some cases, the diagnoses contradicted the patients' own doctors' views.

2. How did the insurers make these new diagnoses?

• The insurers added diagnoses after reviewing medical charts, sometimes using artificial intelligence, and sending nurses to visit patients in their homes.
• They paid doctors for access to patient records and rewarded patients who agreed to home visits with gift cards and other financial benefits.

3. What was the financial impact of these insurer-driven diagnoses?

• Medicare paid insurers about $50 billion for diagnoses added just by insurers in the three years ending in 2021.
• Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company.

[02] Impacts on Patients and Care

1. How did the insurer-driven diagnoses impact patients?

• Some patients were startled by the diagnoses, such as Harriet Siskin who was diagnosed with obstructed arteries by a doctor sent by her insurer, Humana.
• Many patients may never know they have been misdiagnosed by their insurers, and doctors often don't know when insurers have added diagnoses of their patients.

2. What were the issues with the treatment of patients with insurer-driven diagnoses?

• About 18,000 Medicare Advantage recipients had insurer-driven diagnoses of HIV, but less than 17% of them were receiving the necessary antiretroviral treatment.
• Over 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they had already undergone cataract surgery, which is "anatomically impossible" for the condition to return.

[03] Oversight and Reforms

1. What has the government done to address the issues with Medicare Advantage?

• The Centers for Medicare and Medicaid Services (CMS) is making changes to the list of diseases for which insurers earn higher payments, with some of the most heavily used diagnoses, including diabetic cataracts, paying less or nothing extra after the changes take full effect in 2026.
• However, experts believe these changes may not solve the problem, as insurers "will find something else to make up the revenue."

2. What other efforts have been made to address the issues?

• Government contractors audit Medicare Advantage plans and can eventually recoup payouts for inaccurate diagnoses.
• A 2019 whistleblower lawsuit by a Florida doctor alleged that an insurer submitted inaccurate diagnoses, and in 2022, insurer Cigna Group agreed to pay $172 million to settle civil-fraud allegations over its Medicare Advantage practices.