External audit of UnitedHealth senior home visits finds most diagnoses supported by medical data
A newly released audit of UnitedHealth’s home visits for Medicare seniors found little evidence to support accusations that the program, called HouseCalls, drums up extra patient diagnoses to inflate UnitedHealth’s reimbursement from the federal government.
UnitedHealth argued that the results vindicate HouseCalls, which has faced scrutiny from regulators and lawmakers focused on combating profiteering in Medicare Advantage, Medicare’s privatized sister program.
About 96.6% of diagnoses that UnitedHealth found during the home visits were backed up by patients’ health records, according to the audit released Tuesday from FTI Consulting, which used the same review process as the government.
That leaves 3.4% of diagnoses unsupported by medical information — three times lower than the error rate found by the CMS in its most recent audit of data in the privatized Medicare program.
UnitedHealth said it reviewed FTI’s findings and that the lion’s share of diagnoses unsupported by medical records were backed up by other information like paid claims.
The report bolsters UnitedHealth’s defense of its HouseCalls program, in which clinicians perform an in-home assessment of a Medicare member’s health needs. UnitedHealth maintains the home visits are valuable for making preventive care easily accessable for seniors, and for understanding a broader array of patient needs than what might present in a doctor’s office.
However, critics argue that HouseCalls is a key pathway enabling the insurance giant to improperly inflate its reimbursement in MA.
In the privatized Medicare program, payments to insurers are adjusted based on how sick their members are. That creates a significant financial incentive for managed care companies to root out more diagnoses or exaggerate the conditions seniors have.
In-home risk assessments performed in programs like HouseCalls make it easy for insurers to get creative with recordkeeping, skeptics say.
A government investigation in 2024 found that major MA payers, including UnitedHealth, were receiving billions of dollars in overpayments by submitting questionable diagnoses to Medicare that were dug up during health risk assessments. The largest share of overpayments were connected to home visits to Medicare enrollees through programs like HouseCalls, the HHS Office of the Inspector General found.
Of the $7.5 billion that flowed to MA plans through in-home health assessments in 2023, UnitedHealth received $3.7 billion, according to the report.
UnitedHealth has vehemently defended how it records and submits diagnoses to the federal government.
But amid souring public sentiment and civil and criminal probes into its Medicare billing — and following the company’s first quarterly earnings miss since 2008 — CEO Stephen Hemsley pledged to commission and release an outside review of UnitedHealth’s business practices shortly after returning to the chief executive role last spring.
UnitedHealth released the first tranche of results in December. The review found areas for improvement but no smoking gun showing the company is leveraging its control of the industry in order to inflate profits, as critics allege. UnitedHealth said it would share a more detailed look into HouseCalls this year.
In the newly released report, FTI Consulting reviewed a random sample of 200 HouseCalls visits representing 494 diagnoses, and found 17 diagnoses that were not supported by the medical record. UnitedHealth said it reviewed the diagnoses and found that most of them were supported by other data. FTI then agreed that 12 of the 17 diagnoses were backed up by paid claims.
A UnitedHealth spokesperson did not respond to questions about how much it received in MA reimbursement for the 17 initially unsupported diagnoses, or how much in reimbursement the 3.4% error rate would represent if extrapolated across UnitedHealth’s entire business.
UnitedHealth said the results are a clear sign of integrity for the HouseCalls program, but that there’s always more to do to ensure only valid diagnoses are submitted to the CMS.
“While these are meaningful results, we are committed to doing better,” Hemsley said in a statement.
Hemsley said that he will continue to subject “key practices” at UnitedHealth to independent review and that results would be shared publicly.
The CEO also announced publicly that the company has implemented all 23 recommendations that auditors, including FTI Consulting and the Analysis Group, laid out in December, including establishing an independent team to audit coding and formalizing risk assessment oversight policies.
