UnitedHealth’s Army of Doctors Helped It Collect Billions More From Medicare

The biggest Medicare Advantage insurer presented physicians with checklists of potential diagnoses; ‘I didn’t think I was obese’

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

"The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.

More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.

Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans"

"Sickness scores for those UnitedHealth patients increased 55%, on average, in their first year in the plans, the analysis showed. That increase was roughly equivalent to every patient getting newly diagnosed with HIV, the virus that causes AIDS"

"That far outpaced the 7% year-over-year rise in the sickness scores of patients who stayed in traditional Medicare"

"Across Medicare Advantage plans run by all insurers, including UnitedHealth, scores for all newly enrolled patients rose by 30% in the first year."

"Medicare’s system of paying for diagnoses was developed by the government, not any one insurer"

"Traditional Medicare patients treated by UnitedHealth doctors had much lower sickness scores"

"Patients of the medical groups operated by UnitedHealth have unusually high sickness scores compared with those of other doctors’ practices"

"Patients who both saw UnitedHealth doctors and were enrolled in UnitedHealth plans had the highest average sickness scores in the Journal’s analysis of claims from 2019 to 2022. Those higher sickness scores triggered about $4.6 billion more in Medicare payments than UnitedHealth would have received if those patients’ scores had been in line with the average for the company’s other Medicare Advantage patients."