Last August I posted a story on how home nursing visits were being used by insurance companies to bilk Medicare for billions. (Home Nursing Visits Bilking Medicare for Billions)

The story was reported in The Wall Street Journal by Anna Wilde Mathews, Christopher Weaver, Tom McGinty, and Mark Maremont. They discovered that insurance companies were instructing their home nurses who visited Medicare Advantage patients to add diagnoses to the patient record whenever possible to increase payments from the federal government.

Now these same investigative reporters have uncovered similar activity by doctors working for the UnitedHealth Group. Their report in The Wall Street Journal reveals how the insurer prepared a checklist of potential diagnoses even before the patients were examined. Here’s how they described the situation:

“Like most doctors, Nicholas Jones prefers to diagnose patients after examining them. When he worked for UnitedHealth Group, though, the company frequently prepared him a checklist of potential diagnoses before he ever laid eyes on them.

UnitedHealth only did that with the Eugene, Ore., family physician’s Medicare Advantage recipients, he said, and its software wouldn’t let him move on to his next patient until he weighed in on each diagnosis. The diagnoses were often irrelevant or wrong, Jones said. UnitedHealth sometimes suggested a hormonal condition, secondary hyperaldosteronism, that was so obscure Jones had to turn to Google for help. “I needed to look it up,” he said.”

The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.

More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.

The authors say, “Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans, according to the Journal’s analysis of Medicare data between 2019 and 2022. Sickness scores for those UnitedHealth patients increased 55%, on average, in their first year in the plans, the analysis showed. That increase was roughly equivalent to every patient getting newly diagnosed with HIV, the virus that causes AIDS, and breast cancer, the analysis showed.”

That far outpaced the 7% year-over-year rise in the sickness scores of patients who stayed in traditional Medicare, according to the analysis. Across Medicare Advantage plans run by all insurers, including UnitedHealth, scores for all newly enrolled patients rose by 30% in the first year.

A spokesman for UnitedHealth said in a written statement that the company’s practices lead to “more accurate diagnoses, greater availability of care and better health outcomes and prevention, including less hospitalization, more cancer screenings and better chronic disease management.” The company’s approach, he said, helped to avert more serious health problems later, and to achieve Medicare Advantage’s goals of improving quality and reducing costs.

It is revealing that Dr. Jones, the Oregon doctor mentioned above, said UnitedHealth didn’t suggest diagnoses for patients he treated outside Medicare Advantage, where it doesn’t pay. Traditional Medicare patients treated by UnitedHealth doctors had much lower sickness scores, the Journal’s analysis showed.

UnitedHealth has acquired dozens of medical groups over the past decade-and-a half. Its Optum unit now employs about 10,000 physicians, its top executive has said, making it one of the nation’s largest employers of doctors. It contracts with tens of thousands more. No other national insurer has acquired and hired doctors on that scale.

In my opinion, the company is rationalizing their policies to justify the additional diagnoses that lead to much higher payments from the government. This is exactly why I abhor the recent trend of doctors leaving private practice to work for insurance companies, hospitals, and other large corporations. This inevitably leads to doctors compromising their judgements about diagnosis and treatment due to pressure from their employers. Doctors need to make decisions based on what’s best for the patient, not their employer.