UnitedHealth Upcoded Medicare Advantage Claims to Get More $$, Senate Report Says

 UnitedHealth Group (UHG) is artificially inflating risk adjustment scores of patients in its Medicare Advantage plans in order to get higher reimbursement, according to a report from Sen. Chuck Grassley (R-Iowa) and his staff, although the plan is disputing that claim.

"My investigation has shown UnitedHealth Group appears to be gaming the system and abusing the risk adjustment process to turn a steep profit," Grassley said in a press release Monday, the day the report was issued. "Taxpayers and patients deserve accurate, clear-cut, and fair risk adjustment processes."

The report is based on a review of 50,000 pages of documents that UHG provided to Grassley and his staff -- including internal training materials, policies, software documentation, and audit tools -- as well as publicly available information. "After a review of the records, this report provides evidence that shows UHG has turned risk adjustment into a major profit-centered strategy, which was not the original intent of the program," the report said. "Staff discovered that UHG uses aggressive strategies to maximize these risk adjustment scores and that UHG appears to be able to leverage its size, degree of vertical integration, and data analytic capabilities to stay ahead of CMS's efforts to counteract unnecessary spending related to coding intensity."

What "aggressive strategies" did UHG use to get these higher risk adjustments, according to the report? They included:

• Nurse practitioners employed or contracted by UHG to visit enrollees in their homes and assess current health status (known as in-home health risk assessments)
• Coders employed or contracted by UHG to conduct secondary chart reviews of external medical records in order to identify documented conditions not listed on invoices
• External providers who are paid or incentivized by UHG to assess enrollees for certain diagnoses and submit the corresponding diagnosis codes (known as "pay-for-coding")
• Formally and informally integrated primary care providers and specialists whose diagnosis capture workflows are controlled by UHG

Grassley's staff outlined numerous examples of possible upcoding. For instance, regarding coding for opioid dependence, "UHG guidance tells providers to diagnose 'physical dependence' of opioids in patients who take prescribed opioids as directed and would have withdrawal syndrome due to 'abrupt cessation' or 'rapid dose reduction' -- meaning an enrollee does not need to have experienced withdrawal symptoms to receive the diagnosis," Grassley noted in the release. "By doing so, UHG can capture certain diagnostic codes for opioid dependence that apply to moderate and severe opioid use disorder, even in patients taking prescribed opioid medications as directed for pain."

"The investigation has also shown that risk adjustment in Medicare Advantage has become a business in itself -- by no means should this be the case," the report concluded. "MAOs [Medicare Advantage organizations] should receive payments that are commensurate to the complexity and acuity of the Medicare beneficiaries that they insure, not their knowledge of coding rules and their ability to find new ways to expand inclusion criteria for diagnoses."

UHG pushed back against the report's findings. "We ... disagree with the committee's characterizations of our Medicare Advantage coding practices and HouseCalls program," UHG said in an emailed statement. "Our programs comply with applicable CMS requirements and have, through government audits, demonstrated sustained adherence to regulatory standards. Our programs are subject to rigorous clinical quality controls and compliance safeguards. We are proud of the compassionate care our HouseCalls clinicians deliver to seniors every day."

The Better Medicare Alliance, a trade group for Medicare Advantage plans, gave a more measured response. "In-home health assessments help identify conditions that might otherwise be missed and ensure medical records reflect a person's full health needs each year," Susan Reilly, the alliance's vice president of communications, said in a statement. "We support strong standards and oversight already in place, including a robust audit system. Any efforts to improve the program should protect the tools seniors rely on for affordable, comprehensive care and supplemental benefits."

Healthcare consumer groups, in contrast, supported the report. "The Center for Medicare Advocacy agrees with the conclusion from the report that Medicare Advantage organizations are able to exploit the current risk adjustment system to make more money without focusing on improving care or outcomes for people enrolled in their plans," Kata Kertesz, the center's managing policy attorney, said in an email. "We urge additional congressional oversight of MAOs. We also urge CMS to use its existing authority to limit this harmful upcoding. CMS should remove diagnosis codes that exclusively come from chart reviews or health risk assessments that are not substantiated in other visits with medical providers."

"Additionally, we believe that an outcomes-based system would provide proper incentives to provide the care beneficiaries actually need, while making it more difficult for plans to game the system," said Kertesz. "Overall, this report underscores what we already know about Medicare Advantage plans: they are a profit-driven industry operating with a strong focus on their bottom line."

AARP didn't address the report's findings specifically but sent a more general statement. "Protecting seniors' health through Medicare is a top priority," a spokesperson said in an email. "We appreciate any effort to protect and strengthen Medicare."

A few days after Grassley issued his report, Kaiser Permanente agreed to pay $556 million to settle fraud allegations related to its Medicare Advantage plan. According to the complaint, which was consolidated with other similar complaints in a northern California federal court, from 2009 through 2018, Kaiser Permanente added roughly half a million diagnoses that generated about $1 billion in improper payments to the health plan. In its settlement agreement, the health plan did not admit any wrongdoing.

https://www.medpagetoday.com/publichealthpolicy/medicare/119481