'Rampant abuse of the system': Insurers made patients appear sicker — pocketing $50 billion from Medicare for diseases doctors didn't treat, WSJ analysis finds

But Lee’s doctor later told her she didn’t have diabetes, let alone the cloudy vision sometimes caused by the disease. The Journal notes, however, the insurer, a unit of UnitedHealth Group, would have benefited from the nurse’s diagnosis, as Medicare pays insurers more for sicker patients — up to around $2,700 more a year for those with diabetic cataracts at the time.

Private insurance companies involved in Medicare Advantage — a government program in which private insurers oversee Medicare benefits — made hundreds of thousands of dubious diagnoses from 2018 to 2021 that triggered extra taxpayer-funded payments, according to an analysis by the Journal, and Medicare paid insurers around $50 billion for diagnoses added just by insurers to patient records.

How these diagnoses were made

Instead of saving Americans money on the costs of care, the report suggests Medicare Advantage has added billions of dollars in costs. Medicare permits insurers to add their own diagnoses to ones submitted by patients’ doctors. The analysis, however, found many diagnoses were added for which patients received no treatment or contradicted their doctors’ opinions. Some questionable diagnoses included diabetic cataracts and HIV.

Private insurers pay doctors to review medical charts, according to the Journal, and offer financial benefits, like gift cards, to patients who agree to home visits. This can gave way for diagnoses to be added. Last year, Cigna Group agreed to pay $172 million to settle a lawsuit filed by the Justice Department over its Medicare Advantage practices for allegedly using in-home health risk assessments and having medical coders conduct chart reviews to help report severe health conditions and increase payments.

In its analysis, the Journal says it found that some diagnoses were made that doctors were unaware of and patients received no care for, or that were apparently false. As an example, over 66,000 Medicare Advantage patients were found to be diagnosed with diabetic cataracts even though they already had gotten cataract surgery.

“It’s anatomically impossible,” Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham, told the Journal. “Once a lens is removed, the cataract never comes back.”

Meanwhile, another 36,000 diabetic cataract patients apparently didn’t receive any treatment related to diabetes.

Similarly, around 18,000 Medicare Advantage patients were found to be diagnosed with HIV through their insurers, but weren’t receiving treatment from their doctors. Each HIV diagnosis generated about $3,000 a year in added payments to insurers, according to the Journal.

Insurers call the analysis 'inaccurate' and 'flawed'

The Journal’s analysis showed insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated resulted in a stunning $8.7 billion in payments to the company in 2021.

UnitedHealth spokesman Matthew Wiggin told the publication its analysis was “inaccurate and biased,” and that Medicare Advantage “provides better health outcomes and more affordable health care for millions of seniors” than traditional Medicare. He added that the additional payments helped cover the cost of medical care, reduced premiums and provide other benefits for Medicare Advantage members.

He also called the analysis flawed because it correlates insurer diagnoses with subsequent medical care, and said the COVID-19 pandemic disrupted care and lowered treatment rates during the period that was analyzed by the Journal.

Another spokesperson from major insurer Humana called the Journal’s analysis “flawed and misleading,” noting its internal data showed more of its HIV patients diagnosed through home visits were getting treated than the Journal found.