Do you or a loved one have a Medicare Advantage health insurance plan? If you are enrolled in Medicare and your medical insurance card has a health plan name and logo (such as United Healthcare, Humana, BCBS, CVS/Aetna, Kaiser, Centene, or Cigna), you like half of Medicare enrollees, have a Medicare Advantage plan. Medicare Advantage plans are arrangements whereby the federal government pays a private insurance company to provide your Medicare benefits. These plans offer more benefits than traditional Medicare and can be quite appealing. Most Medicare Advantage enrollees are happy with their choice and trust their plan to provide good healthcare.
Suppose your trusted plan tells you that they would like to send a nurse practitioner or other healthcare professional to your home to assess your health and health risks and that the visit will be free and conveniently scheduled. Should you accept? Maybe. The assessment may be part of a sincere effort by your health plan to improve your health and reduce your health risks or it may simply be a way for your health plan to generate more revenue, without any direct benefit to you. Telling the difference is challenging.
Medicare Advantage plans are responsible for helping you reduce your health risk and, when needs arise, making sure you get the right healthcare, at the right time, in the best location. It is therefore in both your and your plan's interest for your plan and your physicians to have a comprehensive understanding of your health and health risks. Home risk assessments can provide a more comprehensive assessment of your health and risks than standard 10- to 15-minute office visits to your physicians and can lead to health plan actions that will improve your health and reduce your health risks.
But, there are also powerful incentives for health plans to use home visits to simply catalog your health conditions, both real and exaggerated, and take no action. The federal government pays Medicare Advantage plans monthly premiums for the people that the plans enroll. Each person's premium is adjusted according to their health profile. The more chronic and severe diseases that a person has, the higher the premium and the more your plan profits. An additional diagnosis code on an enrollee's annual medical record can increase the premium for that person anywhere from a few hundred to tens of thousands of dollars per year. Collecting premiums for additional diagnoses and taking no subsequent actions is, at least in the short term, a profit-generating strategy for health plans.
Most of the large organizations offering Medicare Advantage plans have been named in past or present lawsuits alleging that they have improperly added inaccurate, poorly documented, or non-documented diagnosis codes to member records in pursuit of risk adjustment payments. Furthermore, late last year, the U.S. Attorney's Office for the Southern District of New York filed suit against Cigna specifically for retaining vendors to send nurse practitioners to members to identify diagnosis codes.
According to the government, "The healthcare providers... who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor and were not reported to CIGNA by any other healthcare provider who saw the patient during the year in which the home visit occurred."
U.S. Attorney Damian Williams said, "As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members. CIGNA knew that, under the Medicare Advantage reimbursem*nt system, it would be paid more if its plan members appeared to be sicker."
Medicare Advantage home visits are not unique to Cigna. When your health plan proposes sending a nurse or other healthcare professional to your home, know that:
- You are under no obligation to let anyone visit your home, nor are you under obligation to otherwise have a health assessment.
- Health assessments should benefit your health and not just your health plan's bottom line.
- You should ask, upfront, whether the visiting nurse will be able to treat any identified issues and whether, and how, your primary care and other doctors will be informed of issues and risks.
- You should ask for and receive a summary of the assessment.
- You have the right to all your healthcare records, including the records generated from your assessment.
- You have the right to demand a correction of any error(s) in any of your healthcare records.
- If your home visit reveals new health issues or risks, you should proactively follow up with your primary care and other physicians and not assume that the follow-up communication and care, even if promised, will happen.
- You can report Medicare Advantage fraud and abuse by calling Medicare directly.
Healthcare plans can be complicated, and Medicare Advantage plans are no exception. There are steps you can take, however, to ensure you're receiving the best care and that your plan supports your health.
