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

Questionable diagnoses of HIV and other maladies triggered extra Medicare Advantage payments; ‘It’s anatomically impossible’

By Christopher Weaver, Tom McGinty, Anna Wilde Mathews and Mark Maremont of The WSJ. Excerpts:

"Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021, including outright wrong ones"

"The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea."

"Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs"

"insurers can add diagnoses to ones that patients’ own doctors submit."

"many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views."

"Insurers added diabetic cataract diagnoses to 148 patients treated by Dr. Howard Chen, an ophthalmologist in Goodyear, Ariz. He said he saw at most one or two such cases a year."

"Medicare paid insurers about $50 billion for diagnoses added just by insurers in the three years ending in 2021"

Diabetic cataracts are a complication of diabetes that occur when uncontrolled blood sugar damages the lens of the eye, clouding a person’s vision.

"UnitedHealth members were about 15 times as likely to have that diagnosis [Diabetic cataracts] as the average patient in traditional Medicare" relatively rare disease."

"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."

"Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery"

"About 18,000 Medicare Advantage recipients had insurer-driven diagnoses of HIV, the virus that causes AIDS, but weren’t receiving treatment for the virus from doctors, between 2018 and 2021"

"Each HIV diagnosis generates about $3,000 a year in added payments to insurers."

"Less than 17% of patients with insurer-driven HIV diagnoses were on them"

"The Medicare data, however, show UnitedHealth’s patients with insurer-driven HIV diagnoses were on the antiretrovirals at low rates even before the pandemic, and hardly any started the drugs in the years after UnitedHealth diagnosed them."

"'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."

"Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company"

"UnitedHealth’s net income that year was about $17 billion."

"Academic researchers and government investigators have raised questions about high rates of insurer-driven diagnoses in Medicare Advantage. In a 2021 report, the inspector general that oversees Medicare found the agency spent billions of dollars based on insurer-driven diagnoses for which patients received no care from doctors."

"For Medicare Advantage insurers, a big difference between the two forms of cataracts is that the government only pays extra for the diabetic ones. "

"Some insurers interpreted U.S. guidelines for recording diagnoses in the broadest possible way, labeling patients with diabetes and any kind of cataract with the more lucrative diagnosis. They did it even when doctors said the patients only had the old-age form of the disease or had no diabetic complications at all, the data show."

"Former employees said UnitedHealth also uses the visits to add diagnoses. A HouseCalls home-visit training manual, which was reviewed by the Journal, describes software used on the laptops that workers carry on home visits. According to the manual, the software offers suggestions about what illness a patient might have—and even adds some automatically to a “diagnosis cart.”"