Dive Brief:
- One of the latest whistleblower cases ever filed accuses a medical consulting firm and two dozen health plans of conducting in-home elderly exams that allegedly overstated how much Medicare should be paid.
- The latest lawsuit, filed in Dallas by a medical billing coder, Becky Ramsey-Ledesma, against her employer, CenseoHealth LLC, names 30 Medicare Advantage plans in 15 states, including several Blue Cross plans and Humana.
- Medicare Advantage plans differ from standard Medicare in that it gets a set monthly fee for each patient based on a risk score that pays higher for those in poor health. The plans have become very popular and now cover about 17 million people.
Dive Insight:
Medicare Advantage has firm congressional support and the Centers for Medicare and Medicaid has issued a statement saying home exams can provide "significant value." CenseoHealth is a major player in the in-home assessment market, with a network of 5.000 physicians and in 2013 the company forecast revenue of $120 million.
The Dallas lawsuit said the company used an algorithm to identify patients with potential undetected medical conditions that could raise their risk scores. Marketers were used to contact patients and arrange physician home visits. The lawsuit alleges that no medical treatment was provided, no physical exam and no lab tests performed at the home visits. Rather the physicians only take vital signs and then ask patients a series of questions and charge a flat fee of $100. Some physicians lacked medical licenses and some faked results, according to the lawsuit.
Although CMS raised concerns in 2013 about home visits improperly raising risk scores and wasting tax dollars, the agency backed down after facing industry pressure. The insurance industry estimated that cutting home visits would have cost Medicare Advantage plans close to $3 billion a year.
CMS ruled out excluding home visits this year and instead suggested the industry adopt a set of "best practices" for the visits. A press release issued at that time quoted Andy Slavitt, then CMS deputy administrator, saying the proposals "would reward providers of high-quality, consumer-friendly care" for Medicare Advantage.