Grassley Report of UnitedHealth Group takes aim at these 20 diagnoses: Here’s why

By Brian Murphy

 

The Grassley Report examining the risk adjustment practices of UnitedHealth Group (UHG) is much more than just a one-time media splash.

The report is 105 pages long and contains a wealth of information and insight into how UHG does its work. This includes the criteria it uses to report diagnoses to CMS for care funding.

The report states that UHG’s loose and permissive diagnostic definitions equates to gaming the system. It examines 20 total diagnoses in detail, including the following:

1. Asymptomatic peripheral artery disease
2. Polyneuropathy in non-diabetic patients
3. Diabetes
4. Hyperlipidemia
5. Osteoporosis
6. Atrial fibrillation
7. Heart failure
8. Chronic obstructive pulmonary disease
9. Rheumatoid arthritis
10. Secondary immunodeficiency
11. Secondary hyperaldosteronism
12. Secondary hypercoagulable state
13. Chronic Respiratory Failure
14. Opioid dependence
15. Morbid obesity due to excess calories
16. Unspecified angina
17. Protein calorie malnutrition
18. Dementia
19. Alcohol use disorder
20. Senile purpura

 

Let’s take a look at a few of the report findings.

 

Alcohol Use Disorder

Per Grassley Report investigators, UHG has directed its providers to diagnose patients with “alcohol use, unspecified” and “unspecified alcohol-induced disorder” if an alcohol disorder is present but definitive criteria for either “abuse” or “dependence” cannot be determined.

 

Opioid dependence

Per Grassley, UHG guidance tells providers to diagnose “physical dependence” of opioids in patients who take prescribed opioids as directed and would have withdrawal syndrome due to “abrupt cessation” or “rapid dose reduction.” Meaning, an enrollee does not need to have experienced withdrawal symptoms to receive the diagnosis. By doing so, UHG can capture certain diagnostic codes for opioid dependence that apply to moderate and severe opioid use disorder, even in patients taking prescribed opioid medications as directed for pain.

 

Dementia

The Alzheimer’s Association recommends screening Medicare beneficiaries for dementia each year through a combination of history-taking and a brief objective cognitive assessment. Patients with a positive screen should receive a full dementia evaluation to determine the appropriate diagnosis. However, the Grassley reports states that based on the documents provided, UHG has taught its providers that dementia can generally be diagnosed with just two of the following: “abnormal [objective cognitive assessment], disorientation on [physical exam], memory problems on [review of systems], and loss of independence with [activities of daily living].”

 

The report does acknowledge the complexities of coding, stating that “variation in diagnostic and coding practices can occur without overly aggressive coding or upcoding” due to physician interpretation and varying clinical definitions promulgated by medical specialties. But its array of evidence against UHG implies deliberate variation in one direction—upwards. And it more than insinuates that these practices should not be permissible for risk adjustment.

 

What it means

This is an opportunity to review your own internal diagnostic definitions and thresholds for reporting, with an eye on defensible documentation including evidence of treatment.

We always recommend following evidence-based medicine and diagnostic criteria promulgated by specialty societies and the Official Guidelines for Coding and Reporting as the basis of coding assignment.

The diagnosis dive starts on p. 50 of the report.

 

Reference

• Chuck Grassley, Grassley Report Details UnitedHealth’s Record of Appearing to Game the Medicare Advantage System, Turning Risk Adjustment into Its Own Business: https://www.grassley.senate.gov/news/news-releases/grassley-report-details-unitedhealths-record-of-appearing-to-game-the-medicare-advantage-system-turning-risk-adjustment-into-its-own-business