When his health plan submits data showing he has diabetes without complications, the payment grows by $1,284, MedPAC wrote in March. Additional coding for vascular disease brings in $3,620 more, raising his total to $11,630. The insurer keeps the money even if the patient isn’t treated for either condition.
That’s how Medicare Advantage incentivizes insurers to report as many codes as possible.
Keating, the Boston physician, suspected upcoding in UnitedHealth’s home health assessment of Mrs. G.
Mrs. G. had been diagnosed by the insurance company’s clinician with chronic pain, morbid obesity and Type 2 diabetes with complications for cataracts and a type of nerve damage called polyneuropathy.
In Keating’s diagnosis, Mrs. G had a relatively common spinal malady, but without pain. She was obese, but not morbidly so. She did not have cataracts or polyneuropathy. And while testing put Mrs. G in the pre-diabetic range, she did not have diabetes.
UnitedHealth said it could not respond directly to Keating’s account. But the company said most diagnoses made during in-home visits are not used to generate payments.
Source: Why UnitedHealth’s Medicare Advantage program is under attack
