Insurers Profit from Health Risk Assessment

[somarco]

A federal watchdog found that Medicare Advantage insurers led by UnitedHealth Group collected billions of dollars in dubious payments from Medicare by using home visits and medical chart reviews to diagnose patients with conditions for which they received no follow-up care.

Insurers collectively received an estimated $7.5 billion in payments last year from health risk assessments (HRAs) and related reviews of medical records performed in 2022, a report released Thursday by the Office of Inspector General for the Health and Human Services Department concluded. The diagnoses added during those assessments were not found in any of the patients’ other medical records that year, suggesting that they were either inaccurate or that patients did not get potentially necessary care for serious conditions, the report found.

UnitedHealth collected billions in questionable Medicare payments, federal watchdog finds

Insurers diagnosed patients with serious conditions, but they sometimes received no followup care, HHS OIG found.

www.statnews.com

Perhaps the patients were miraculously healed after enrolling in these plans . . . .

 

[BALDELMO]

 

[LeeV]

This is an interesting article, and I have no idea whether it is true or not. But something did strike me as odd. By way of an example, I work for an insurance carrier that provides specific stop loss to a TPA and their self-funded clients. Furthermore, I am also the person responsible for the program. The TPA has devised a scheme to inflate claims so that more claimants hit the Spec point, causing the carrier to payout monies that should not have been paid. This has been going on for years, we/carrier investigate and figure it out. As the person in charge of the program, should I not be held responsible?

Now the odd thing. Isn't Medicare the stop loss carrier in this analogy? Why is there no accountability and responsibility at Medicare?

 

[scagnt83]

This is an interesting article, and I have no idea whether it is true or not. But something did strike me as odd. By way of an example, I work for an insurance carrier that provides specific stop loss to a TPA and their self-funded clients. Furthermore, I am also the person responsible for the program. The TPA has devised a scheme to inflate claims so that more claimants hit the Spec point, causing the carrier to payout monies that should not have been paid. This has been going on for years, we/carrier investigate and figure it out. As the person in charge of the program, should I not be held responsible?

Now the odd thing. Isn't Medicare the stop loss carrier in this analogy? Why is there no accountability and responsibility at Medicare?

Because congress has taken half a billion a year away from Medicare and given it to MAPD Carriers. Making Medicare grossly understaffed.