MESSAGE
| DATE | 2024-08-06 |
| FROM | Ruben Safir
|
| SUBJECT | Subject: [Hangout - NYLXS] In a day loaded with news,
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https://www.msn.com/en-us/money/companies/the-one-hour-nurse-visits-that-let-insurers-collect-15-billion-from-medicare/ar-AA1oekCQ
This was reported originally in today's Wall Street Journal and it
covers in detail just ONE approach that the Medicial Thrid Party
Providers rip off the public to the amount of BILLIONS of dollars while
real healthcare providers are being ripped off and their careers
destroyed. What you see here is just ONE example of how the system
encourages theft and wrecks the healthcare market.
Everyone needs to read this and you need to get you congressmen and
elected officials to read it.
Mind you, this is all going on when the drug companies are forcing
atients to load up with 90 day supplies of drugs and trying to normalize
this grossly irrespancible action and while they pay Pharmcies 67 and 24
cents for a majority of scripts.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The One-Hour Nurse Visits That Let Insurers Collect $15 Billion From
Medicare
Story by Anna Wilde Mathews, Christopher Weaver, Tom McGinty, Mark Maremont
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 nurses aren’t there to treat anyone. They are gathering new
diagnoses that entitle private Medicare Advantage insurers to collect
extra money from the federal government.
A Wall Street Journal investigation of insurer home visits 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. Those payments
added up to about $15 billion during that period, according to a Journal
analysis of Medicare data.
Nurse practitioner Shelley Manke, who used to work for the HouseCalls
unit of UnitedHealth Group, was part of that small army making home
visits. She made a half-dozen or so visits a day, she said in a recent
interview.
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. The insurers were checking for cases of
peripheral artery disease, a narrowing of blood vessels. Each new case
entitled them to collect an extra $2,500 or so a year at that time.
But Manke didn’t trust the device. She had tried it on herself and had
gotten an array of results. 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.
“It made me cringe,” said Manke, who stopped working for HouseCalls in
2022. “I didn’t think the diagnosis should come from us, period, because
I didn’t feel we had an adequate test.”
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.
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.
The diagnoses added after home visits accounted for about 30% of that
total. More than 700,000 peripheral artery disease cases diagnosed only
during home visits added $1.8 billion in payments during that period.
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 payments go up when people have
certain diseases, giving insurers an incentive to diagnose those conditions.
To find out how insurers use home visits to add diagnoses, the 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.
“They do the job with a purpose, and it pays off for the Medicare
Advantage plans,” said Francois de Brantes, a former executive at
Signify Health, a company that does home visits for insurers.
“Identifying the diagnoses, that’s the job.”
Insurers, including UnitedHealth and CVS Health, owner of both Signify
and Aetna, said the house calls help patients by, among other things,
catching diseases early and making sure people are taking their medicine
properly. The insurers said they relay home-visit findings to
primary-care doctors.
Nurses who made visits said they felt they were helping some patients
with advice about medications, performing needed tests and sometimes
reporting health emergencies.
For UnitedHealth, the parent company of the largest Medicare insurer,
each home visit was worth about $2,735 in extra Medicare payments during
the three years covered by the data, the Journal analysis found. That’s
nearly three times the average for all other Medicare Advantage insurers.
UnitedHealth’s chief physician, Dr. Wyatt Decker, attributed the
disparity to what he said was UnitedHealth’s sicker patient population
and its nurse practitioners being so effective at their jobs.
Sixty percent of UnitedHealth home visits generated at least one new
revenue-producing diagnosis of a condition no doctor was treating, the
analysis showed. Home visits by Humana, the No. 2 Medicare insurer, did
so 39% of the time.
The Journal reviewed Medicare data covering the home visits under a
research agreement with the federal government. The data doesn’t include
patients’ names, but covers details of doctor visits, hospital stays,
prescriptions and other care.
The home-visit industry has grown in recent years. UnitedHealth’s
HouseCalls sent nurse practitioners to the homes of more than 2.7
million people last year. CVS’s Signify performed about 2.6 million home
visits in 2023.
Step one is getting Medicare Advantage recipients to agree to a visit,
especially patients whom insurers deem most likely to have undiagnosed
conditions that would garner extra payments.
Two former managers who oversaw home visits for Humana, and a third who
worked for both Humana and Signify, said insurers used an internal
scoring system to identify prospects. Under the Medicare Advantage
system, 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.
Insurers also considered other factors, including how likely patients
were to agree to a visit, some home-visit executives said.
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. Agents sometimes offered the Medicare recipients
incentives such as Walmart gift cards.
A Humana spokesman said the company is committed to accurately
identifying patients’ health conditions.
Dave Sherwood, a 68-year-old retired accounting executive in
Williamsburg, Va., joined a UnitedHealth Medicare Advantage plan last
year. Earlier this year, he got a flurry of calls from representatives
of the insurer. When he finally answered one, he told them he didn’t
want a home visit.
Months later, he started getting the calls again. Finally, he said, he
picked one up and told the agent to stop calling.
When patients agree to a visit, home-visit companies send nurse
practitioners or, less frequently, doctors or physician assistants. Some
are full-time employees, others contractors who get paid around $100 or
more per visit.
At each home, the nurses run through a series of questions covering
medical history and medications, as well as doing a physical assessment
and some basic testing.
In the HouseCalls system, nurses feed the information into a laptop or
tablet, and the software suggests diagnoses. They automatically appear
in a “diagnosis cart” on the side of the screen, according to training
documents from last year that were viewed by the Journal.
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. 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.”
Secondary hyperaldosteronism, a condition in which levels of the hormone
aldosterone rise, is rarely diagnosed in traditional Medicare patients.
HouseCalls documents show that its software 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. Nurses weren’t required to confirm the diagnosis with a lab test.
“In a million years, I wouldn’t have come up with a diagnosis of
secondary hyperaldosteronism,” said Bell, the former HouseCalls nurse.
UnitedHealth diagnosed it 246,000 times after home visits, 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.
“It is a vastly underdiagnosed condition that is super valuable to call
out,” said UnitedHealth’s Decker.
To find more cases of peripheral artery disease, both HouseCalls and
Signify used the testing device that nurse Manke said she distrusted,
company manuals show.
The Food & Drug Administration said the device, called the QuantaFlo,
“is not indicated for use as a stand-alone diagnostic device but as an
adjunct to the diagnostic process.” Medical guidelines recommend against
widespread screening for the condition.
A HouseCalls training manual advised nurses to diagnose peripheral
artery disease based on results from the device. Managers at Signify
told nurses they were required to use the device to test the patients of
most insurers, a 2020 email shows.
Nurses diagnosed the condition after 568,000 home visits to UnitedHealth
patients in the period analyzed by the Journal, adding up to nearly $1.4
billion in additional payments.
UnitedHealth’s Decker said the company expected clinicians to use their
judgment in making peripheral artery disease diagnoses. A spokesman for
Signify-owner CVS said medical providers decide when the test is
appropriate on a case-by-case basis, and that the 2020 email was “not
clearly worded” and didn’t reflect company policy.
Renae Cormier, chief financial officer of QuantaFlo maker Semler
Scientific, said the device assesses risk for the disease.
Dr. Amy Chappell, a 73-year-old neurologist in Naples, Fla., was
surprised when a nurse sent to her house earlier this year by
UnitedHealth pulled out a QuantaFlo device. “She had no reason to think
I had peripheral artery disease,” said Chappell, who says she has had no
symptoms of the condition and is an avid runner and tennis player.
Chappell tested positive, although the nurse didn’t do any other
standard exam to check for symptoms of the disease, Chappell said. Her
primary-care doctor, Dr. Rebekah Bernard, said in an email that the
diagnosis was inaccurate.
“From what I do know of the case, it’s an example of where we could have
done better, and we need to own that,” said UnitedHealth’s Decker. The
company later confirmed the diagnosis was a mistake and said it corrects
such errors.
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
inspector general that oversees the Medicare agency has said it should
reconsider the use of such diagnoses.
A spokeswoman for the Centers for Medicare and Medicaid Services, said
the agency recently ramped up audits to verify diagnoses. The agency
also is eliminating some diagnoses from those that qualify for extra
payments, including peripheral artery disease.
Nathanael Lacaria, a nurse practitioner who did home visits in Colorado
for CVS’s Signify unit in 2019 and 2020, said he didn’t feel it was
appropriate to make definitive diagnoses based on one visit.
He said he didn’t realize insurers were submitting some of his tentative
diagnoses to Medicare for billing purposes until a woman he had visited
called the company to complain. “What’s this depression diagnosis in my
chart?” she asked, according to Lacaria.
When he visited the woman, whose husband had died, Lacaria said, he
recorded her answers to a standard depression screening tool, but he
hadn’t actually diagnosed depression. “These visits were definitely used
to jump to conclusions I wouldn’t have arrived at,” he said.
The CVS spokesman said Signify’s clinicians independently determine
which conditions a patient has.
Write to Anna Wilde Mathews at Anna.Mathews-at-wsj.com, Christopher Weaver
at Christopher.Weaver-at-wsj.com, Tom McGinty at Tom.McGinty-at-wsj.com and
Mark Maremont at Mark.Maremont-at-wsj.com
--
So many immigrant groups have swept through our town
that Brooklyn, like Atlantis, reaches mythological
proportions in the mind of the world - RI Safir 1998
http://www.mrbrklyn.com
DRM is THEFT - We are the STAKEHOLDERS - RI Safir 2002
http://www.nylxs.com - Leadership Development in Free Software
http://www.brooklyn-living.com
Being so tracked is for FARM ANIMALS and extermination camps,
but incompatible with living as a free human being. -RI Safir 2013
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