Why does my Medicare Advantage plan keep calling me to schedule a home visit?

My sister-in-law recently asked me why her Medicare Advantage plan was repeatedly leaving voicemails asking her to set up a home visit. The messages offer to pay her $50 to do so. The money was tempting but she had concerns about the legitimacy of the calls.

She’s not the only one getting such requests. A Consumer Rescue reader submitted a similar question, asking if Medicare rules require her to agree to a visit.

If you’re enrolled in a Medicare Advantage plan, chances are you’ve gotten or will get such a call. That has to make one wonder why the plans are willing to pay people to make the calls. Also, why are they so persistent, and why are they willing to pay you for the visits?

What’s behind these calls?

To understand what’s going on, you have to first understand how Medicare Advantage (MA) plans work.

These are plans sold by private insurance companies that receive a negotiated, set fee per patient from Medicare (regardless of treatment required) to provide medical coverage for their enrollees.

Medicare bases those fees on the reported health status of their enrollees. That health status is measured by risk scores which are calculated based on diagnoses the plans report to Medicare. MA plans use a health assessment to collect that information, usually when someone first enrolls in a plan via a “Welcome to Medicare” office visit. Then plans try to update the status at least yearly during Medicare’s “Annual Wellness Exam.”

The Medicare Advantage plans are paid a risk-adjusted rate per patient based on the patient’s health and reported diagnoses. The higher the risk score, the higher the payment the plan gets.

So, for example, a person with a risk score of 1.0 would be expected to incur medical treatment costs equal to the average Medicare beneficiary. A person with a risk-adjusted score of 2.0 would be expected to cost the plan twice as much and the plan would get a higher payment.

The idea is that plans should be fairly compensated for the costs of services regardless of the beneficiaries’ health conditions.

Health risk assessments

Medicare Advantage plans have the ability to review a member’s medical chart to see if there might be health conditions that are not reflected in claims submitted by providers. The plans also can do Health Risk Assessments (HRAs), which are questionnaires that collect information from a beneficiary about their health history, current conditions, and family medical history, along with other concerns and risk factors. Finding more healthcare conditions and possible risk factors can lead to the Medicare Advantage plan receiving higher risk-adjusted payments.

The plans can use home visits to conduct Health Risk Assessments and chart reviews. They generally use nurse practitioners to conduct the home visits. Sometimes the HRAs and chart reviews are conducted by third-party companies hired for that purpose.

Are Medicare Advantage plans gaming the system?

Here’s the problem. Unlike Medicare’s original fee-for-service (FFS) model where a doctor or other provider only gets compensated when they see or treat a patient, MA plans receive the same monthly payment even if they don’t see or treat the enrollee for anything at all.

Critics say Medicare Advantage plans are pushing home visits in order to find more diagnoses that can increase member risk scores and resulting payments from Medicare regardless of whether they treat those conditions. Using chart reviews and HRAs to increase payments from Medicare without providing or improving care for those diagnoses is called “upcoding,” and it can result in overpayments and improper payments by Medicare.

In testimony before a congressional committee, the Office of the Inspector General of the Department of Health and Human Services said that some Medicare Advantage plans collected more than $9 billion in payments for diagnoses from chart reviews and HRAs that were otherwise not treated in 2017, the most recent year for which they had data:

Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs to maximize risk-adjusted payments. We found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.

Accusations of fraud and over-billing

Many critics say those payments have grown since 2017 as MA plans have gotten more aggressive with doing home visit HRAs. Last October, the federal government filed a civil fraud lawsuit against Cigna for such practices. According to the announcement from the United States Attorney for the Southern District of New York:

The Government’s complaint alleges that the reported diagnoses codes were based solely on forms completed by vendors retained and paid by Cigna to conduct in-home assessments of plan members. The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by Cigna from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor and were not reported to Cigna by any other healthcare provider who saw the patient during the year in which the home visit occurred.  Nevertheless, Cigna submitted these diagnoses to the Government to claim increased payments and falsely certified on an annual basis that its diagnosis data submissions were “accurate, complete, and truthful.”

Cigna isn’t the only insurance company accused of overbilling Medicare. According to a New York Times report, nine of the top ten providers of MA insurance plans have been accused in court of fraud or overbilling Medicare.

Medicare Advantage was supposed to save dollars for the system

Medicare Advantage was created by Congress as a privatized alternative to FFS Medicare. It was promoted as a cost-saving program, but the reality has been different. The Medicare Payment Advisory Commission (MedPAC), the independent Congressional agency that advises on issues affecting the Medicare program, said in its March, 2023 report to Congress:

Medicare spends 6 percent more for MA enrollees than it would spend if those beneficiaries were enrolled in FFS Medicare, a difference that translates into a projected $27 billion in 2023.

The MedPAC report in March was followed by a Senate bill co-sponsored by U.S. Senators Bill Cassidy, (R-LA) and Jeff Merkley, (D-OR). Titled the “No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act”, it would prohibit the use of chart reviews and HRAs in determining the fees MA plans negotiate and ensure that Medicare is only charged for treatment for relevant medical conditions.

What should you do about those calls from your MA plan?

• If you get one of those calls, first be sure it’s not some kind of scam. There is a big red flag to keep in mind: If the caller asks you for personal identifying information, especially your Medicare number, hang up. I wrote about Medicare fraud scams in this article.
• If the caller left a voicemail message, you might want to contact your plan to determine if it really was from them. But use the phone number on your insurance ID card instead of the number in the voice mail.
• If the call is actually from your health plan, then decide whether you want to participate.

Home visits can be a good thing if they are part of your plan’s preventative health benefits for target populations. They can be very helpful to Medicare beneficiaries who have serious medical conditions, are homebound or have difficulty getting to a health care provider. They can help prevent complications and hospitalizations.

But understand that the typical HRA visit as pitched by many MA plans is not part of an ongoing care program. While the results will be forwarded to your plan and possibly your doctor, that doesn’t mean it will lead to improved access or care.

If you’re in good health, but the HRA visit results in a higher risk score, it won’t affect your MA plan premium. But it could result in the plan getting a possibly undeserved payment increase from Medicare, further driving up costs for the program.

Is that something you want?

And for our Consumer Rescue reader who wanted to know – Medicare does not require you to agree to a home visit, no matter what the caller implies. (Abe Wischnia, Consumer Rescue)

*Before you go: Want to save money on your Medicare prescription plan? Here are some strategies.