In Part I of this series, we learned that home nursing visits are being used by private insurers to bilk the taxpayers for billions in additional Medicare funding. In Part II we will see who is abusing the system the most and how they do it.

The Wall Street Journal reported on an investigation into the home nursing industry and found home nurses were adding billions to the cost of Medicare. To find out how insurers use home visits to add diagnoses, the Journal interviewed nurses, patients, home-visit managers and industry executives and reviewed hundreds of pages of internal documents from home-visit companies. They described a system that used nurses, software and audits to generate diagnoses.

“They do the job with a purpose, and it pays off for the Medicare Advantage plans,” said Francois de Brantes, a former executive at Signify Health, a company that does home visits for insurers. “Identifying the diagnoses, that’s the job.” Insurers, including UnitedHealth and CVS Health, owner of both Signify and Aetna, said the house calls help patients by, among other things, catching diseases early and making sure people are taking their medicine properly. The insurers said they relay home-visit findings to primary-care doctors.

Nurses who made visits said they felt they were helping some patients with advice about medications, performing needed tests and sometimes reporting health emergencies. For UnitedHealth, the parent company of the largest Medicare insurer, each home visit was worth about $2,735 in extra Medicare payments during the three years covered by the data, the Journal analysis found. That’s nearly three times the average for all other Medicare Advantage insurers.

UnitedHealth’s chief physician, Dr. Wyatt Decker, attributed the disparity to what he said was UnitedHealth’s sicker patient population and its nurse practitioners being so effective at their jobs. (No surprise there!) Sixty percent of UnitedHealth home visits generated at least one new revenue-producing diagnosis of a condition no doctor was treating, the analysis showed. Home visits by Humana, the No. 2 Medicare insurer, did so 39% of the time.

Step one is getting Medicare Advantage recipients to agree to a visit, especially patients whom insurers deem most likely to have undiagnosed conditions that would garner extra payments. Two former managers who oversaw home visits for Humana, and a third who worked for both Humana and Signify, said insurers used an internal scoring system to identify prospects. Under the Medicare Advantage system, diagnoses have to be documented every year to trigger the extra payments, so people who had an earlier home visit that produced extra payments were particularly valued, the managers said. Insurers also considered other factors, including how likely patients were to agree to a visit, some home-visit executives said.

The Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress, has recommended that diagnoses from home visits shouldn’t count toward extra payments to Medicare insurers. The inspector general that oversees the Medicare agency has said it should reconsider the use of such diagnoses. A spokeswoman for the Centers for Medicare and Medicaid Services, said the agency recently ramped up audits to verify diagnoses. The agency also is eliminating some diagnoses from those that qualify for extra payments, including peripheral artery disease.

This is the kind of investigative journalism we need more of and my hat’s off to the Journal for this in-depth look at the home nursing industry. We cannot afford this kind of wasteful spending if our Medicare system is to survive.

It’s bad enough that the Biden/Harris Administration is expanding the rolls of Medicaid and therefore increasing the taxpayer’s burden. But now add to that scandal what’s happening to Medicare when that friendly nurse comes to visit your home.

In a new article published in The Wall Street Journal, the authors reveal how private insurance companies are bilking the government for billions. Anna Wilde Mathews, Christopher Weaver, Tom McGinty, and Mark Maremont now reveal the results of an intensive investigation into the home nursing business. Here’s how they describe what is happening:

“Millions of times each year, insurers send nurses into the homes of Medicare recipients to look them over, run tests and ask dozens of questions. The nurses aren’t there to treat anyone. They are gathering new diagnoses that entitle private Medicare Advantage insurers to collect extra money from the federal government. A Wall Street Journal investigation of insurer home visits found the companies pushed nurses to run screening tests and add unusual diagnoses, turning the roughly hourlong stops in patients’ homes into an extra $1,818 per visit, on average, from 2019 to 2021. Those payments added up to about $15 billion during that period, according to a Journal analysis of Medicare data.”

Nurse practitioner Shelley Manke, who used to work for the HouseCalls unit of United Health Group was part of that small army making home visits. She made a half-dozen or so visits a day, she said in a recent interview. Part of her routine, she said, was to warm up the big toes of her patients and use a portable testing device to measure how well blood was flowing to their extremities. The insurers were checking for cases of peripheral artery disease, a narrowing of blood vessels. Each new case entitled them to collect an extra $2,500 or so a year at that time.

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.

Last month WSJ reported that insurers received nearly $50 billion in payments from 2019 to 2021 due to diagnoses they added themselves for conditions that no doctor or hospital treated. Many of the insurer-driven diagnoses were outright wrong or highly questionable, the Journal found. The diagnoses added after home visits accounted for about 30% of that total. More than 700,000 peripheral artery disease cases diagnosed only during home visits added $1.8 billion in payments during that period.

How could this be happening?

That’s a good question and one that should be asked by those in the federal government in charge of Medicare – the Center for Medicare and Medicaid Services (CMS). This abuse of the system is happening particularly in the Medicare Advantage system. In the Medicare Advantage system—conceived as a lower-cost alternative to traditional Medicare—private insurers get paid a lump sum to provide health benefits to about half of the 67 million seniors and disabled people in the federal program. The payments go up when people have certain diseases, giving insurers an incentive to diagnose those conditions. But the system should not be paying for diagnoses not made by the treating physician. Allowing home nurses to add diagnoses is simply letting the fox into the chicken coop.

(Note: For more on this subject, stay tuned for my next post – Part II of this series.)

It’s no secret there are passionate people on both sides of the abortion issue. Pro-life activists believe it is their mission to preserve life in the womb. Pro-abortion people believe it is a women’s “right to choose” abortion rather than life. But recently it seems that there is a nationwide campaign by some state governments to take away a women’s right to choose if they choose life.

Sierra Dawn McClain, writing in The Wall Street Journal, tells us, “Politicians and attorneys general in states run by Democrats have been on a crusade to make life miserable for pregnancy resource centers, and the campaign has picked up since the Supreme Court struck down Roe v. Wade in 2022. This has included harassing them with legal action and trying to discredit their work.”

Pregnancy resource centers provide women facing unplanned pregnancies with free and low-cost support such as counseling on alternatives to abortion, parenting education, medical referrals and material goods. These centers in 2022 provided clients across the U.S. with services valued at more than $367 million, including more than 500,000 free ultrasounds, 3.5 million packs of diapers and 43,000 car seats according to McClain.

First Choice Women’s Resource Centers is a faith-based New Jersey nonprofit. First Choice has supported more than 36,000 women facing unplanned pregnancies since 1985 and doesn’t charge for its services. Yet rather than praise the nonprofit, New Jersey officials are harassing it because of its pro-life stance. Democratic Attorney General Matt Platkin last November issued a subpoena demanding that it turn over a broad range of documents. He did so under the pretense of conducting a civil investigation into possible violations of state laws and regulations, but attorneys representing First Choice wrote in a court filing challenging the subpoena that Mr. Platkin “has never cited any complaint or other substantive evidence of wrongdoing to justify his demands.”

The attorney general’s order requires First Choice to dig up and hand over documents going back 10 years, including personal information about employees, volunteers, affiliates and donations. “Collecting that information would be completely overwhelming,” Aimee Huber, First Choice’s executive director, said in an interview. “It would take multiple hours per day and take us away from our mission of serving women.” Ms. Huber is also concerned that the information could be used to badger and intimidate the nonprofit’s pro-life supporters.

A core plank of Mr. Platkin’s investigation is the assertion that First Choice may be misleading the public and thus violating consumer-fraud law. This isn’t the first time he has made such a claim about pregnancy resource centers. Mr. Platkin and the attorneys general of 14 other mostly blue states and the District of Columbia laid out this theory in an open letter in October 2023. They claim that pregnancy centers set up shop near health clinics, use deceptive tactics to lure in women seeking abortions, then give them misleading information about the procedure to trick them into carrying their babies to term.

McClain says, “It’s no secret that pregnancy resource centers are pro-life and that they inform their clients about the potential negative physical and mental health effects of abortion. It’s also well known that these nonprofits consider it a win—for the mother and her child—when she chooses not to have an abortion. First Choice states on its website and in conversations with clients that it doesn’t provide or refer for abortions. Yet Mr. Platkin’s consumer-fraud argument is one piece of a broad smear campaign. In December 2022 his office issued a consumer alert warning the public to be wary of the centers, which “seek to prevent people from accessing comprehensive reproductive health care.”

This is not an isolated effort by the attorney general. Emails obtained through a public-records request show that the attorney general’s office asked Planned Parenthood, the nation’s largest abortion provider, to preview and edit the draft consumer alert before it was issued—a clear conflict of interest. In addition to slamming pregnancy centers, the consumer alert urged women seeking abortions to check out Planned Parenthood’s website. The attorney general’s office and Planned Parenthood declined to comment on their collaboration.

It is clear from this situation that those who claim they are “pro-choice” only want women to have a choice if they choose abortion.