What Do Managed Care Plans Really Want from Providers of Services to Patients in Their Homes? 

Medicare Managed Care Plans have a long history of disinterest in provision of services to patients in their homes. Despite the fact that they are mandated to provide the same services that enrollees in Medicare fee-for-services receive, they just haven’t done it. Common practices among Plans of draconian, untimely pre-authorization processes and doling out authorizations for visits a few at a time make it clear that Plans have seen no real value in services to patients at home.  

Plans, of course, should have been very interested in services at home. These services save money and keep patients at home where they want to be. Services at home are just generally a beautiful thing! 

At the same time, it’s fair to say that the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), the primary enforcer of fraud and abuse prohibitions, has Medicare Managed Care Plans in its crosshairs. A key area of concern for the OIG is that Medicare Managed Care Plans make visits to patients in their homes looking for additional diagnoses so that the Plans will receive more money per patient. The OIG is especially critical of this practice because review of medical records of patients who received visits at homes and whose acuity increased as a result never received any care for these new diagnoses.  

The Wall Street Journal recently reported that between 2018 and 2021 Plans received $50 billion for diagnoses added to members’ charts, at least some of which resulted from visits to patients in their homes. 

After years of disinterest, Plans are now quite interested in at home services. Is it possible that Plans’ newfound interest is related to a desire to increase revenue through home visits?  It appears so. Take, for example, comments by the CEO of UnitedHealth Group, Andrew Witty, during an investment call on July 16, 2024. 

Mr. Witty reported to investors that staff made more than 2.5 million home health visits to Plan members in 2023. “As a direct result, our clinicians identified 300,000 seniors with emergent health needs that may have otherwise gone undiagnosed,” Mr. Witty said. “They connected more than 500,000 seniors to essential resources to help them with unaddressed needs.” 

Former UnitedHealth employees told The Wall Street Journal that home visits were used to add diagnoses to patients’ records. They said that clinicians used software during visits that offered suggestions about what illnesses patients might have.  

It now looks like it’s possible that at-home care is being hijacked by Medicare Advantage Plans to help Plans engage in practices that the OIG views as questionable. Please say it ain’t so! 

©2024 Elizabeth E. Hogue, Esq. All rights reserved. 

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