UnitedHealth’s billing practices draw DOJ investigation, Wall Street Journal coverage

By Jason Jobes, SVP, Solutions

 

DOJ ALERT: The Wall Street Journal is reporting that UHC is under investigation for Medicare Advantage (MA) billing practices. Why, and what should you know?

 

Thanks for reading Mid-Revenue Cycle Minute. Don’t forget to follow me on LinkedIn where I share content like this regularly.

 

The WSJ released a report on Friday (see link below) that the DOJ has stepped up investigations into UHC’s MA billing practices. It isn’t clear to me in the article what is being investigated but there are some things being called out that warrant attention.

 

My readers know we have talked about the pendulum swinging from revenue maximization to revenue protection (risk score accuracy). It is vital for MA plans, ACOs, and those in risk-based contracts to get risk scores accurate.

 

A few things get called out in the article:

 

1) Provider incentives. The article calls out incentives to providers to capture risk conditions. I have no problem with, and actually encourage, provider incentives for focusing on risk conditions documentation. However, it shouldn’t be done blindly and there must be checks and balances. Providers are not coders and have lived in a fee-for-service world most of their practicing lives. Some incentives to align organizational goals should occur. We do this for HEDIS measures which drive up colonoscopy and mammogram volumes.

 

2) Optum HouseCalls is called out for their in-home visits driving $2300 per member more of payments per year. I posted about in-home visits last year and I know for a fact that many organizations use partners to drive this practice. On the surface, it looks bad, but access to primary care is very constrained. This service provides a need to help those that don’t come in to the office and/or provide more access. Sometimes these services can be great. Norwood just evaluated coding accuracy for a large vendor in this space and the risk code accuracy was an astounding 98.9%. Again, leverage a service like this for your risk program but implement checks and balances.

 

3) Capturing obscure conditions. The article calls out UHC focusing on capturing hyperaldosteronism. Data mining continues to identify conditions that are undercaptured, but this is where we have seen the most overly aggressive capture. A lot of the over capture of conditions like this led to the inaccuracy to predict future costs in V24. In my opinion part of the V28 rollout was aimed directly at the excessive capture of certain conditions. You MUST have a check and balance system to validate the billed diagnoses.

 

From the article:

 

Doctors said UnitedHealth, based in the Minneapolis area, trained them to document revenue-generating diagnoses, including some they felt were obscure or irrelevant. The company also used software to suggest conditions and paid bonuses for considering the suggestions, among other tactics, according to the doctors.

 

Last summer, the Journal also reported that UnitedHealth added diagnoses to patients’ records for conditions that no doctor treated, which triggered an extra $8.7 billion in federal payments in 2021. The untreated diagnoses stemmed from sources including in-home visits by nurses working for the company’s HouseCalls unit. Each visit by the UnitedHealth-employed nurses was worth an average of $2,735 in additional federal payments, a Journal analysis of Medicare data spanning 2019 to 2021 found.

 

Outpatient CDI doesn’t stand alone. When we partner with organizations we work with them on 45 best practices to drive CDI and overall risk score accuracy. We want organizations to document and bill for every condition that exists. We want them to get every penny they deserve—just not a penny more.

 

I believe that we will continue to see fraud, waste, and abuse at the headlines in the MA space. DOGE activity coupled with the new administration has made that clear.

 

Need help? Want to discuss more? Let’s chat. Drop me a message or comment.

 

Reference

 

• Wall Street Journal, “DOJ Investigates Medicare Billing Practices at UnitedHealth”: https://www.wsj.com/health/healthcare/unitedhealth-medicare-doj-diagnosis-investigation-66b9f1db