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Health Insurance Shenanigans

We spend nearly $3 trillion on health care annually in the United States. That works out to about one-sixth of the total economy and nearly $13,000 per person annually — way more than any other wealthy country. If the health-care system were to break off from the United States and become its own economy, it would be the fifth largest in the world.



We don't get better health outcomes for all this spending, as many of us know. In fact, we are worst among wealthy nations in a number of public health outcomes. A huge problem with our health care system is the profit motive. The industry doesn't want us to think about that. It hides behind a lot of fancy talk, but behavior tells the tale.


Insurance companies have grown devious in their profiteering strategies. Here's an example: I manage my 88-year-old mother's health care, so I'm the one contacted by UnitedHealthcare, her AARP-related Medicare Advantage insurer. A few months ago, I got email after email urging my mom to schedule her "HouseCalls" visit. A medical professional would come to her home for free! There was even a cash incentive: a $15 Visa Reward Card. The promise: You can review your current medications, get important health screenings, and ask any health-related questions you may have." Since my mom already has a wonderful primary care physician (as well as specialists if needed), I didn't answer.


The emails escalated: "Time is running out to schedule a no-cost 2022 health check-in." The incentive went up, too: merely three weeks after the $15 offer, she was offered a $50 reward if she opened her door to a stranger. I kept ignoring the emails, because I knew my mom didn't want or need home visits from unknown medical people. Then the phone calls began. They called me not to ask IF my mom wanted a home visit. The voice on the other end of the line told me it was time to schedule the visit. It wasn't a request; it was a demand.


Can you imagine calling vulnerable elderly person and telling them to schedule a home visit as if it were a requirement of their health insurance? At first, I naively thought that perhaps UnitedHealthcare was trying to cut health care costs. That could be a good thing. But then I learned that we have a national epidemic of insurers trying to get extra federal reimbursements for Medicare patients. Because Medicare pays based on patients' diagnosed conditions rather than on the amount of services a patient needs, the greater the number of diagnoses and the greater their severity, the more Medicare dollars the insurer is likely to get in its pocket.


Statnews.com, which does investigative reporting on important issues related to healthcare, recently published an exposé: "Medicare Advantage plans cost taxpayers more than traditional Medicare... These companies also have a long history of exaggerating how sick their members are, which the Medicare Payment Advisory Commission (MedPAC) said has led to 'significant overpayments to plans.' They do this through a process called risk adjustment, in which monthly federal payments to Medicare Advantage insurers are based on how many health conditions each member has, producing what’s known as 'risk score'.... [S]ome companies have also abused the system by coding as many conditions as possible — the more health problems people have, the higher their risk scores, and the more insurers get paid."


Keep in mind that health insurers have access to patient records. After all, they pay the claims. I bet they come equipped to these home visits with an eye to expanding or otherwise messing with existing diagnoses. There's simply no other logical reason I can think of for them to target people like my mom, who had recently had a full medical check-up with appropriate lab tests from her doctor.


UnitedHealthcare had already had a chance to shape up. Consider this post from The Center for Public Integrity in 2017: "The Justice Department has accused insurance giant UnitedHealth Group of overcharging the federal government by more than $1 billion through its Medicare Advantage plans.... The Justice Department alleged that the insurer made patients appear sicker than they actually were in order to collect higher Medicare payments than the company deserved. The government said it had 'conservatively estimated' that the company 'knowingly and improperly avoided repaying Medicare' for more than a billion dollars over the course of the alleged decade-long scheme."



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