A recent investigation by the Office of Inspector General (OIG) for the Department of Health and Human Services has revealed some troubling findings regarding home diagnosis services under the Medicare program, commonly known as the Red and Blue Card. Despite significant concerns surrounding these services, Medicare is paying private insurers billions of dollars.
According to an exclusive report by the Wall Street Journal, the OIG’s latest findings, released on October 24, 2023, indicate that private insurance companies collected an extra $4.2 billion in federal funding for proactively arranged home diagnoses, even when no subsequent treatments were provided.
The report highlights that private insurers charge $1,869 for each arranged home visit, a figure consistent with a previous investigation by the Wall Street Journal in August. Between 2019 and 2021, these insurers received an average of $1,818 in federal payments for home diagnoses that did not lead to any follow-up care.
For the first time, the OIG has recommended that Medicare limit or even eliminate the home diagnosis arrangements made by private insurance companies. However, this recommendation was rejected by Medicare regulators, who cited a limited scope of research.
Medicare Advantage plans are viewed as beneficial for elderly individuals and those with disabilities, potentially lowering out-of-pocket medical expenses and improving insurance quality. However, the nonpartisan Medicare Payment Advisory Commission (MedPAC) found that, compared to traditional Medicare, Medicare Advantage participants are actually spending more, in part because insurers leverage various strategies to maximize their payments within the system.
These home visits, referred to as health risk assessments, are a critical aspect of how private insurers generate revenue. Nurse practitioners or physicians visit the patients to review their medical history, check their medication status, and perform basic home tests. Interestingly, some test results are unusual and have never appeared in the reports from the patients’ regular doctors.
Erin Bliss, Deputy Inspector General, stated that certain insurers participating in Medicare Advantage have earned billions from health risk assessments without providing any treatment based on the diagnosis results. This raises concerns that the diagnoses may be inaccurate or, if accurate, the insurers are failing to arrange necessary medical care for their patients.
