'Your doctor, insurance company, clinic, hospital can all get paid more if we make you sicker' — Dr. Scott Jensen
How insurers profit from billable diagnoses at patients' expense
Insurance companies are meant to pay doctors for patient diagnoses or reimburse the insured for medical expenses. However, some insurers exploit the system to secure additional reimbursements from the government for Medicare patients.
Conduct home visits to claim patients' sicker
Private Medicare Advantage insurers aiming to increase their profits send nurses and nurse practitioners to make home visits to Medicare patients insured with them. These visits are intended to uncover new ailments that doctors may have missed, which insurers can then bill to the government. This information is passed on to doctors for follow-up.
Dr. Scott Jensen, a physician, has raised concerns about this practice. Based on reports he receives from insurers, he notes that home visits often lead to lists of surprising diagnoses for patients. These exaggerated findings benefit insurers, doctors, clinics, and hospitals by inflating patients' conditions, which triggers higher reimbursements.
As a Wall Street Journal (WSJ) investigative report by Anna Wilde Mathews, et al, revealed, these additional, often questionable, diagnoses add billions of dollars to insurers’ coffers. Mathews' team analyzed Medicare data between 2019 and 2021 and found that insurance companies collected an extra $15 billion from such claims.
Peripheral neuropathy
One questionable practice involved the use of the QuantaFlo device to diagnose peripheral neuropathy, a disease affecting the nerves, raising concerns about accuracy and necessity. The FDA does not approve QuantaFlo as a sole diagnostic tool, and medical guidelines caution against widespread screening for the condition. QuantaFlo manufacturer Semler Scientific said the device measures the risk of disease. Despite this, insurers encouraged or required nurses to use the device during home visits, leading to diagnoses that triggered higher Medicare payments.
Shelley Manke, a nurse practitioner who quit working for such an insurer, said she was uncomfortable with the test for peripheral neuropathy that she was required to do. She was given the device to put on the patient’s toe, after warming it, to check blood flow in the extremities. Each new case they diagnosed brought in an additional $2,500, approximately, during the year.
She tried the device on herself and after receiving several different readings, told her boss that she felt it was unreliable. She wasn't the only nurse who felt that way, but they were told to continue using it.
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.
According to the WSJ’s analysis, one insurer, United Health, pocketed an extra $1.4 billion in additional payments from the diagnosis, over the course of 568,000 home visits to their patients, as shown in its image below.
Avid runner diagnosed with peripheral neuropathy she didn't have
Dr. Amy Chappell’s case is compelling. One of United Health’s insured, the 73-year-old neurologist was diagnosed with peripheral neuropathy as the result of a home visit. She was surprised that the test was even done.
“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.
Her doctor confirmed the misdiagnosis and the insurance company acknowledged the error and corrected its records.
Rare disease garners millions for insurers
Another, very unusual, diagnosis that insurance companies have made on their own is secondary hyperaldosteronism, signifying an increase in aldosterone, a hormone “essential for sodium conservation in the kidney, salivary glands, sweat glands, and colon.”
Secondary hyperaldosteronism, a condition in which levels of the hormone aldosterone rise, is rarely diagnosed in traditional Medicare patients. HouseCalls [a division of United Health] 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.
Kristen Bell, a nurse practitioner who left HouseCalls, said she would never have come up with such a diagnosis.
“In a million years, I wouldn’t have come up with a diagnosis of secondary hyperaldosteronism.”
United Health and other insurers received millions of dollars from this diagnosis, as pictured in the WSJ’s image below.
Everyone wins but the patient
Dr. Jensen almost lost his medical license for his outspoken stance against the CDC’s narrative about COVID-19, yet took to the internet once again (see his tweet below), this time to warn people that their doctors, insurance companies, clinics, and hospitals all get paid more if they can make them sicker.
I am not exaggerating when I tell you, if you are a patient your doctor, your insurance company, your clinic, your hospital. We can all get paid more if we make you sicker. . . .
So, I’ve been getting a lot of patients lately. They’ve been coming in and say, “Hey Dr. Jensen, a nurse stopped out at my house the other day and had me do a bunch of different things. What’s that all about?”
“And I would hold up some papers and I would say, “Oh, I’ve got it right here.”
So here’s one patient. We’ll just call him John Doe to de-identify him. Someone calls him and says “We’d like to come to your house and just do sort of a house call at your house. So very convenient for you.”
They don’t tell the patient, John Doe, and if you let me come in your front door then I’ll get paid $100, $150, or $200. And, if I can complete this house call survey on you then my employer will get paid more potentially by the government or by the insurance company . . .
This was John Doe [a gentleman in his 80s] and he had this person come out and there were all kinds of recommendations. But, it’s a seven-page report I got. . . . The findings of his mini house call is that he’s at a moderate to high risk of falling, that his sensation to his feet is impaired indicating a problem with neuropathy. He didn’t realize that he was morbidly obese due to excess calories, but he is. He doesn't use a CPAP machine but he does have obstructive sleep apnea, along with a multitude of other diagnoses that he didn’t know he had. And, he now can also be classified as having peripheral vascular disease because of one of the tests that was done when this nurse was there.
He was advised that he was supposed to take a tetanus shot, a Prevnar 15, a Prevnar 20, colorectal cancer screening. He is also supposed to see me for advice regarding use of the various over-the-counter chemicals and bad habits.
So, I added it up and if John Doe comes to me and does all the things that he’s been told to do, based on this, it’ll probably come to be somewhere around $5,000 to $10,000 without breaking a sweat.
Okay. So why is this being done?
This patient’s on Medicare. His insurance company will get paid more by Medicare if this patient is seen as more sick. . . .
Medicare and Medicaid respond
The WSJ reported that Medicare and Medicaid plan to increase audits to verify diagnoses and eliminate certain diagnoses from qualifying for extra payments. The Medicare Payment Advisory Commission, a nonpartisan agency advising Congress, has recommended that diagnoses from home visits should never count toward additional reimbursements. “The inspector general that oversees the Medicare agency has said it should reconsider the use of such diagnoses.”
Critics will monitor whether stricter oversight succeeds in protecting patients and taxpayers from abuse.
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The information contained in this article is for educational and information purposes only and is not intended as health, medical, financial, or legal advice. Always consult a physician, lawyer, or other qualified professional regarding any questions you may have about a medical condition, health objectives, or legal or financial issues.
