are making billions from Medicare Advantage plans using questionable diagnoses.


President-elect Donald Trump and his nominee


to head the Health and Human Services Department, Robert F. Kennedy Jr., have vowed to tackle America’s healthcare crisis and “make America healthy again,” saying the time is right for a healthcare revolution. They report for duty on Jan. 20.


insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two


decades to cover more than half of the 67 million seniors and disabled people on Medicare. Instead of saving taxpayers money,


Medicare Advantage has added tens of billions of dollars in costs, research- ers and some government officials have said. One reason is that insurers can add diagnoses to those patients’ own doc- tors submit. Medicare gave insurers that option


so they could catch conditions doc- tors neglected to record. The Journal’s analysis, however, found many diag- noses were added for which patients received no treatment, or that contra- dicted their doctors’ views. The insurers make new diagnoses


after reviewing medical charts, some- times using artificial intelligence, and


sending nurses to visit patients in their homes. They pay doctors for access to


patient records and reward patients who agree to home visits with gift cards and other financial benefits. The government pays insurers a


base rate for each Medicare Advan- tage member. The insurers are entitled to extra money when their patients are diagnosed with certain conditions that are costly to treat, like morbid obesity. That gives insurers an incentive to


search for additional diagnoses. The result is that many of their patients seem sicker — at least on paper. Diabetic cataracts are a compli-


cation of diabetes that occur when uncontrolled blood sugar damages the lens of the eye, clouding a person’s vision.


UnitedHealth members were about


15 times as likely to have that diagno- sis as the average patient in traditional Medicare, the Journal analysis found. Eye doctors interviewed by the


Journal said it was implausible that such a large share of UnitedHealth’s patients could have the relatively rare disease. The government paid all Medicare Advantage insurers more than $700 million from 2019 to 2021 for diabetic cataracts. Most of the diagnoses were added by insurers.


UnitedHealth spokesman Matthew


Wiggin said the Journal’s analysis was “inaccurate and biased,” and that Medicare Advantage “provides better health outcomes and more affordable healthcare for millions of seniors” than traditional Medicare. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract sur- gery, which replaces the damaged lens of an eye with a plastic insert. “It’s anatomically impossible,” said


Dr. Hogan Knox, an eye specialist at University of Alabama at Birming- ham. “Once a lens is removed, the


cataract never comes back.” About 18,000 Medicare Advantage recipients had insurer-driven diagno- ses of HIV, the virus that causes AIDS, but weren’t receiving treatment for the virus from doctors between 2018 and 2021, the data showed. Each HIV diag- nosis generates about $3,000 a year in added payments to insurers. Everyone with HIV should be on antiretroviral drugs, the only effective treatment, and nearly all Medicare patients whose doctors diagnosed the virus took the drugs. Less than 17% of patients with insurer-driven HIV diagnoses were on them, the Journal found. A spokesman for Humana, the second-biggest Medicare Advantage insurer, provided a written statement that said the Journal’s analysis of treatment rates for people with insur- er-driven diagnoses “is flawed and misleading.” When Congress conceived of the


Medicare Advantage program decades ago, the hope was that insurers would make Medicare more efficient. The idea behind Medicare Advan-


tage was to pay private insurers a lump sum to cover all services, giving them an incentive to keep patients healthier. To protect insurers from the risk


of winding up with sicker-than-aver- age patients, the government allowed bigger payments for certain serious health conditions. Partly because of that, Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medi- care would have cost without the help of the private plans, according to a March report by the Medicare Pay- ment Advisory Commission, or Med- PAC, a nonpartisan agency that advis- es Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.


Tom McGinty, Anna Wilde Mathews, and Mark Maremont contributed to this report.


JANUARY 2025 | NEWSMAX 19


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