Medicare Advantage Plans Overcharge $70 billion for Home Visits

Health plans are cashing in on home visits, taking advantage of Medicare profits when the house calls unearth patients’ medical problems, according to a report by The Center for Public Integrity, a nonprofit investigative news organization in Washington, D.C.

Some senior citizens are finding that their Medicare Advantage health plans were eager to send a doctor to visit them at home, a service that is part of a burgeoning medical information and data analysis industry that’s thriving behind the scenes. Health plans profit because Medicare pays them higher rates for sicker patients, using a billing formula known as a “risk score,” The Center for Public Integrity reports. 

Medicare made nearly $70 billion in “improper” payments to Medicare Advantage plans from 2008 through 2013, “mostly overbillings based on inflated risk scores,” the investigation shows. 

Doctors and nurses who visit patients’ homes don’t offer any treatment during their visits, but report their findings to primary care physicians. And when a home visit uncovers a medical condition, health plans may raise a person’s risk score and cash in on thousands of dollars in added Medicare revenue, even if they don’t incur additional expenses when treating the patient. More than 70 health conditions may push up the risk scores, and thus the payments made by Medicare. 

Risk scores at one plan, Maryland-based XLHealth Corp., jumped by at least 20% between 2007 and the end of 2011, a time when the plan’s home visits mushroomed, according to the Center’s analysis of Centers for Medicare and Medicaid Services data. 

This system of overcharging the government by billions of dollars every year has flourished as federal officials struggle to prevent the Medicare Advantage plans from hiking up their bills, The Center for Public Integrity investigation shows.  

In February, CMS officials drafted regulation that would have restricted these visits, saying that they had seen “little evidence” that medical care “is substantially changed or improved as a result” of the home visits. However, officials bowed to industry pressure in April and backed off the proposal. Limiting home visits could have cut payments to Medicare Advantage plans by nearly $3 billion a year, according to the investigation. 

Scott Weiner, a Virginia Medicare billing expert, told The Center for Public Integrity that health plans which don’t bill aggressively “will lose out to competitors” that do. “It’s keeping up with the Joneses,” he said.

Medicare expects to pay the health plans more than $150 billion this year, and CMS officials are stepping up audits called Risk Adjustment Data Validation this year, hoping to recoup about $370 million in overpayments tied to previously inflated risk scores. 

The debate on home visits continues, as proponents say health professionals can remedy dangerous conditions before they result in a trip to the emergency room or days in the hospital, while opponents argue that only about four out of every 1,000 home visits uncovers maladies serious enough to require immediate attention, The Center for Public Integrity investigation reports.  

To read the full investigation, click here. 

Written by Emily Study