If you’re a Medicare Advantage client, chances are good that you receive frequent phone calls, post cards, and letters inviting you to schedule an in-home medical screening visit. These visits are offered at no charge, sometimes by third-party contractors, and are described as a valuable service to help you receive the personalized care you need.

It turns out that these house calls are valuable, all right – but maybe not so much for the policy-holder as for the insurance company. According to this just-published Wall Street Journal exposé, over a two-year period, these in-home visits allowed the nation’s Medicare Advantage insurance companies to reap a Medicare windfall of some $15 billion. In several cases, they did so by “diagnosing” health conditions using discredited or suspect testing methods.

While there are times when an in-home medical visit may be appropriate and necessary, we were shocked to read just how common and how lucrative these house calls have become. The Wall Street Journal report, written by four staff reporters, helped us understand why companies push these so-called services so relentlessly.  Let’s take a deeper look. (Please note that a subscription may be required to access the Journal article online.)

Millions of House Calls Designed to Boost Insurers’ Revenue

“Millions of times each year, insurers send nurses into the homes of Medicare recipients to look them over, run tests and ask dozens of questions,” the Journal reports. But the real purpose might not be what it seems. 

“The nurses aren’t there to treat anyone,” the article goes on. “They are gathering new diagnoses that entitle private Medicare Advantage insurers to collect extra money from the federal government.”  

Thus begins the report of a Wall Street Journal investigation of insurer home visits. The reporters “found the companies pushed nurses to run screening tests and add unusual diagnoses, turning the roughly hourlong stops in patients’ homes into an extra $1,818 per visit, on average, from 2019 to 2021.”  The visits paid off handsomely. “Those payments added up to about $15 billion during that period, according to a Journal analysis of Medicare data.”

House Call Whistleblower Didn’t Trust Her Own Tests

The reporters sp0ke with several medical professionals who quit their jobs and stopped making home visits out of frustration with the scheme. One was nurse practitioner Shelley Manke, who used to work for the HouseCalls unit of UnitedHealth Group. The article calls Manke “part of that small army making home visits” who said she made a half-dozen or so visits a day.

The Journal article describes how one common in-home test worked.  “Part of her routine, she said, was to warm up the big toes of her patients and use a portable testing device to measure how well blood was flowing to their extremities,” states the report. “The insurers were checking for cases of peripheral artery disease, a narrowing of blood vessels.”

They had good reason to hunt down cases, according to the article. That’s because “each new case entitled them to collect an extra $2,500 or so a year at that time.”

But as the article discloses, Manke didn’t trust the testing device. “She had tried it on herself and had gotten an array of results,” the Journal reveals. “When she and other nurses raised concerns with managers, she said, they were told the company believed that data supported the tests and that they needed to keep using the device.”

Manke, who quit working for HouseCalls in 2022, told the Journal reporters, “It made me cringe. I didn’t think the diagnosis should come from us, period, because I didn’t feel we had an adequate test.” 

Nurses Pushed to Make Unwarranted Diagnoses

Manke was not alone. As the article states, “Other nurses interviewed by the Journal said many of the diagnoses that home-visit companies encouraged them to make wouldn’t otherwise have occurred to them, and in many cases were unwarranted.”

In a previous exposé last month, the Journal reported that insurers received nearly $50 billion in payments from 2019 to 2021 “due to diagnoses they added themselves for conditions that no doctor or hospital treated. Many of the insurer-driven diagnoses were outright wrong or highly questionable, the Journal found.”

Nearly one-third of those questionable diagnoses came as a result of home visits. Peripheral artery disease alone accounted for some 700,000 cases, all diagnosed solely during home visits, for which insurers received an added $1.8 billion in payments.

MA System Incentivizes Diagnosing More Conditions

A big part of the underlying problem lies in how MA plans work. “In the Medicare Advantage system—conceived as a lower-cost alternative to traditional Medicare—private insurers get paid a lump sum to provide health benefits to about half of the 67 million seniors and disabled people in the federal program,” the article explains. “The payments go up when people have certain diseases, giving insurers an incentive to diagnose those conditions.”

In order to discover how insurers use home visits to add diagnoses, reporters for the Wall Street Journal “interviewed nurses, patients, home-visit managers and industry executives and reviewed hundreds of pages of internal documents from home-visit companies. They described a system that used nurses, software and audits to generate diagnoses.” 

As one former executive with Signify Health put it, “They do the job with a purpose, and it pays off for the Medicare Advantage plans. Identifying the diagnoses, that’s the job.”

UnitedHealth alone reported home visits to more than 2.7 million patients last year, says the article. Out of all those visits, 60 percent generated at least one new revenue-producing diagnosis.

“Bombarding” Patients Deemed Likely to Have Undiscovered Ailments

Insurers use several analytic tools to screen their best prospects. Medicare Advantage beneficiaries first have to agree to a home visit. Former managers describe an internal scoring system to identify prospects.

“Under the Medicare Advantage system,” the Journal explains, “diagnoses have to be documented every year to trigger the extra payments, so people who had an earlier home visit that produced extra payments were particularly valued, the managers said.”

The effort to garner appointments is relentless. “Call centers bombard Medicare recipients with offers of home visits—in the case of Humana, autodialing them as many as 10 times, according to the former managers,” the Journal reports. “Agents sometimes offered the Medicare recipients incentives such as Walmart gift cards.”

Routine Questions Prompt Software to Suggest Diagnoses

Once a patient has agreed to a visit, companies dispatch a nurse practitioner, or occasionally a doctor or physician assistant. Some work for the home visit companies while others are contractors earning around $100 or more per visit. 

“At each home,” the Journal reports, “the nurses run through a series of questions covering medical history and medications, as well as doing a physical assessment and some basic testing.”  This medical data is then fed into a laptop or tablet, and (at least in the HouseCalls system) the software suggests diagnoses which automatically appear in an on-screen “diagnosis cart.”

“Kristen Bell, a nurse practitioner who left HouseCalls in May after doing home visits for seven years, said the prompts were one way to prod nurses to add diagnoses,” the Wall Street Journal reveals. “They also got regular training about conditions they could record, she said. She characterized the message from management as: ‘I’m not going to beat you up about this, but I want you to go in this direction.’”

One Rarely-Diagnosed Condition Meant $450 Million in Revenue

The Journal article describes one specific example – a condition called “secondary hyperaldosteronism.”  It’s a condition in which levels of the hormone aldosterone rise, and (says the article) the condition “is rarely diagnosed in traditional Medicare patients.”  But the software used by HouseCalls “would suggest the diagnosis if a patient had a history of heart failure or cirrhosis, and either took certain drugs, such as diuretics, or had swelling due to fluid retention.”

According to the article, nurses weren’t required to confirm the diagnosis with a lab test.  One former HouseCalls nurse called it a diagnosis she wouldn’t have come up with “in a million years.”  Yet, says the article, this rarely-diagnosed ailment proved to be a jackpot.

“UnitedHealth diagnosed it 246,000 times after home visits,” says the Wall Street Journal, “leading to $450 million in payments over the three years of the Journal’s analysis. All other Medicare insurers combined collected $42 million from making that diagnosis after home visits.” 

Device Used for Screening Despite FDA Guidelines

In a similar way, both HouseCalls and Signify sought to increase diagnoses of peripheral artery disease by using a testing device called the QuantaFlo. The FDA, says the article, has stated that the device “is not indicated for use as a stand-alone diagnostic device but as an adjunct to the diagnostic process.” The article adds that medical guidelines recommend against widespread screening for the condition.

Yet nurses with both HouseCalls and Signify were either urged or required to use the device to test the patients of most insurers, a 2020 email shows. The resulting boost in diagnoses of peripheral artery disease meant nearly $1.4 billion in additional payments to UnitedHealth during the time period analyzed by the Journal.

Overdue Policy Changes May Be Forthcoming

It does appear that the practice of using home visits as a tool for over-diagnosis has finally caught the attention of policy-makers.

“The Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress, has recommended that diagnoses from home visits shouldn’t count toward extra payments to Medicare insurers,” the Journal reports. “The inspector general that oversees the Medicare agency has said it should reconsider the use of such diagnoses.”

The Centers for Medicare and Medicaid Services is auditing patient records more closely to verify diagnoses. CMS is also eliminating some diagnoses – including peripheral artery disease – from the list of those that trigger extra payments.

Hopefully, these and other preventive measures will curb the practice of using home visits as a tool to pad profits by adding unverified diagnoses to the charts of unsuspecting patients. Our advice, as always, is to make certain you have a primary care doctor who understands geriatric medicine thoroughly. Find a geriatric doctor you trust and follow their advice.

Moreover, before the visiting nurse comes into your home, be an informed consumer. Don’t be afraid to ask, “Is this medical test really necessary?”

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(originally reported at www.wsj.com)