Insurers banked $50 billion from Medicare for nonexistent treatments
A new report from the Wall Street Journal has shown how insurance companies in the U.S. are taking advantage of loopholes and cashing in on Medicare for treatments that were never actually diagnosed or treated by a doctor.
According to the report, one patient was diagnosed with diabetic cataracts by a registered nurse, despite the fact she didn’t have diabetes, nor cloudy vision after she consulted with her own physician following the RN’s diagnosis.
The patient’s health insurer – part of the UnitedHealth Group – gets an additional $2,700 per year for patients diagnosed with diabetic cataracts.
After the WSJ analyzed billions of Medicare records, it was found that private insurers involved in the federal government’s Medicare Advantage program made thousands of suspicious diagnoses between 2018 and 2021 – that were all eligible for extra payments to insurance companies.
These included diseases such as AIDS, for which the report notes patients did not receive any type of follow-up care, as well as conditions the person could not possibly have. Oftentimes, the patient and their physician had no idea this was occurring.
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 https://t.co/wO1CNHNjfX https://t.co/wO1CNHNjfX
— The Wall Street Journal (@WSJ) July 8, 2024
Private insurers oversee Medicare benefits for Medicare Advantage – a $450 billion per year system – that was born from the notion that a more economical healthcare system could be delivered by private insurers.
The report points out that the program has ballooned by tens of billions of dollars per year in costs, namely because insurers can add a diagnosis to one submitted by the policy holder’s own physician to “catch conditions.”
The WSJ further notes their analysis found many of these added diagnoses included no treatment for patients, or they directly contradicted their physicians’ views. It was also found these new diagnoses were often made after an insurer had viewed medical charts, had used artificial intelligence, or sent registered nurses to visit a patient in his or her home.
In total, it was found that over $50 billion in diagnoses had been added solely by insurers between 2018 and 2021. Around 18,000 Medicare Advantage recipients had insurer-diagnoses of HIV – the precursor to AIDS – which adds $3,000 per year in additional payments to insurers, and less than 17% of these patients were on antiretroviral drugs.
UnitedHealth Group and another insurer, Humana, dispute these claims.
However, a recent report from the U.S. Office of the Inspector General found that insurance company Cigna intentionally made enrollees appear more sick to get additional funds from the federal government. As a result, Cigna was ordered to pay the government $172 million for overcharging Medicare and penalties for fraud.
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