According to an exclusive report from The Wall Street Journal, an analysis of billions of Medicare records showed private insurers connected to the federal government’s $450 billion-a-year Medicare Advantage program issued “hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021.”
The Journal noted that the program currently covers more than half of the 67 million seniors and disabled people on Medicare. It explained that insurers can add their own diagnoses in addition to the ones doctors submit for their patients.
“Medicare gave insurers that option so they could catch conditions that doctors neglected to record,” the Journal stated, adding, “The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views. The insurers make new diagnoses after reviewing medical charts, sometimes using artificial intelligence, and sending nurses to visit patients in their homes.”
“They pay doctors for access to patient records, and reward patients who agree to home visits with gift cards and other financial benefits,” the Journal asserted.
Between 2018 and 2021, Medicare compensated insurers roughly $50 billion for diagnoses the insurers had added.
“The government paid all Medicare Advantage insurers more than $700 million from 2019 to 2021 for diabetic cataracts. Most of the diagnoses were added by insurers,” the Journal reported. Over 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts despite the fact they had previously received cataract surgery.
“It’s anatomically impossible,” Dr. Hogan Knox, an eye specialist at the University of Alabama at Birmingham, told the Journal. “Once a lens is removed, the cataract never comes back.”
UnitedHealth spokesman Matthew Wiggin responded to the Journal’s report by saying its analysis was “inaccurate and biased.” He stated that Medicare Advantage “provides better health outcomes and more affordable healthcare for millions of seniors” than traditional Medicare. A spokesman for Humana echoed that the Journal’s analysis of treatment rates “is flawed and misleading.”
However, the Journal claimed that more than a dozen experts said the news outlet’s methodology was accurate.
