Grassley Report Details UnitedHealth’s Record of Appearing to Game the Medicare Advantage System, Turning Risk Adjustment into Its Own Business

Grassley Report Details UnitedHealth's Record of Appearing to Game the Medicare Advantage System, Turning Risk Adjustment into Its Own Business

Report based on over 50,000 pages of UnitedHealth Group documents provided to Grassley

Report based on over 50,000 pages of UnitedHealth Group documents provided to Grassley

WASHINGTON - Sen. Chuck Grassley (R-Iowa) released a majority staff report exposing UnitedHealth Group's (UHG) record of what appears to be gaming the Medicare Advantage (MA) system, turning risk adjustment into its own business and siphoning off taxpayer money in breach of the program's original intent. Grassley is a senior member and former chairman of the Senate Finance Committee. He currently chairs the Senate Judiciary Committee.

The report, "How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment," is based on a review of over 50,000 pages of UHG documents provided in response to Grassley's congressional oversight requests, including internal training materials, policies, software documentation and audit tools. It shows how the company uses certain resources and strategies to capture a higher number of diagnoses and diagnosis codes than any other Medicare Advantage organization (MAO), resulting in higher payments from the Centers for Medicare and Medicaid Services (CMS) than any of its peers.

"Medicare Advantage is an important option for America's seniors, but as the program adds more patients and spends billions in taxpayer dollars, Congress has a responsibility to conduct aggressive oversight. Bloated federal spending to UnitedHealth Group is not only hurting the Medicare Advantage program, it's harming the American taxpayer. My investigation has shown UnitedHealth Group appears to be gaming the system and abusing the risk adjustment process to turn a steep profit. Taxpayers and patients deserve accurate, clear-cut and fair risk adjustment processes," Grassley said.

Read the full report HERE, and view the documents released by Grassley below:

• Part 1
• Part 2
• Part 3
• Part 4
• Part 5
• Part 6

Background:

More than half of Medicare beneficiaries are currently enrolled in Medicare Part C, known as Medicare Advantage (MA). CMS pays each MAO a monthly, risk-adjusted amount for each beneficiary enrolled in their plans.

The MA risk adjustment is meant to pay MAOs more for sicker enrollees with higher health care expenditures, so MAOs will not avoid enrolling sicker patients. The MA risk adjustment is based on enrollees' diagnoses, as well as demographics. This means enrollees with more diagnoses generally have higher risk scores and generate higher relative monthly payments for MAOs. MAOs with more resources and superior strategies like UHG can capture more diagnoses and diagnosis codes to receive higher payments than less-resourced organizations. This seems contrary to the sixth principle of CMS's Hierarchical Condition Categories (CMS-HCC), "the diagnostic classification should not reward coding proliferation."

Key Findings:

Staff discovered UHG uses aggressive strategies to maximize its risk adjustment scores, appearing to leverage its size, vertical integration and data analytic capabilities to stay ahead of crackdowns by CMS aimed at counteracting overpayments due to coding intensity.

The company's outsized influence among MAOs creates its own concerns. As UHG sells its insights and workforce to other MAOs, the company's actions in response to CMS changes to the risk adjustment model can rapidly permeate the entire MA industry.

Key Finding One: UHG's Specialized Workforce Designed to Drive the Scheme

• UHG's robust diagnosis capture workforce is enhanced by the company's substantial data assets and AI capabilities, including the following:
  • Nurse practitioners employed or contracted by UHG to visit enrollees in their homes and assess current health status (known as in-home health risk assessments or HRAs);
  • Coders employed or contracted by UHG to conduct secondary chart reviews of external medical records to identify documented conditions not listed on invoices;
  • External providers paid or incentivized by UHG to assess enrollees for certain diagnoses and submit the corresponding diagnosis codes (known as "pay-for-coding"); and
  • Formally and informally integrated primary care providers and specialists whose diagnosis capture workflows are controlled by UHG.
• UHG's workforce does more than capture diagnoses used to maximize risk scores. Its in-home HRA providers also screen enrollees, including those in rural areas, for conditions using point-of-care technologies, which reduces barriers and expands access to care.
• Other MAOs contract with UHG to provide in-home HRAs to their enrollees, to retrieve and review the charts of their enrollees and to support their own pay-for-coding programs.

Key Finding Two: UHG's Ability to Rapidly Adapt to CMS Crackdowns

• UHG appears uniquely suited to continuously identify new opportunities to capture untapped risk score-garnering diagnoses, due to its enhanced data assets, AI capabilities and clinical documentation expertise. These opportunities can occur when UHG identifies, in part, through reviews of research studies and recommendations from clinical societies:
  • New screening practices or technologies;
  • Diagnoses that can be made based on probability rather than definitive testing;
  • Diagnoses that can be reflexively applied in the presence of other diagnoses; and
  • Diagnoses that do not have well-defined diagnostic thresholds.
• UHG deploys its in-home HRA, pay-for-coding and integrated provider workforce to capture these targeted diagnoses using the company's circumscribed screening guidelines and diagnostic criteria, with the support of data analytics.
  • UHG-aligned providers document the diagnoses and the criteria supporting the diagnoses in UHG enrollees' medical records, and UHG-aligned medical coders code the diagnoses in alignment with the company's coding guidelines.
• UHG sells its diagnostic criteria and coding guidelines to other MAOs, creating new "standard" definitions for these diagnoses and diagnosis codes within the MA space.
  • With no universally recognized, clear-cut criteria for defining many diagnoses and codes, it is difficult to determine if the criteria perpetuated by UHG is appropriate.

Examples:

Opioids:

Based on the documents provided, UHG guidance tells providers to diagnose "physical dependence" of opioids in patients who take prescribed opioids as directed and would have withdrawal syndrome due to "abrupt cessation" or "rapid dose reduction." Meaning, an enrollee does not need to have experienced withdrawal symptoms to receive the diagnosis. By doing so, UHG can capture certain diagnostic codes for opioid dependence that apply to moderate and severe opioid use disorder, even in patients taking prescribed opioid medications as directed for pain.

Alcohol Use Disorder:

Based on the documents provided, UHG has directed its providers to diagnose patients with "alcohol use, unspecified" and "unspecified alcohol-induced disorder" if an alcohol disorder is present but definitive criteria for either "abuse" or "dependence" cannot be determined.

While UHG guidance states the diagnosis can be made based on the results of alcohol use disorder screening tools (including the four-question CAGE questionnaire), the Diagnostic and Statistical Manual of Mental Disorders (DSM), recognized as the authoritative guide on diagnostic criteria for mental disorders, states a positive CAGE result is not sufficient to make a substance use disorder diagnosis.

In cases when a provider does not change an auto-populated alcohol dependency diagnosis with a more appropriate one within the system, the potentially erroneous diagnosis could stick with the patient in perpetuity. This is due to UHG's instruction directing providers to diagnose enrollees with a past medical history of alcohol dependence with an "alcohol dependence, in remission" diagnosis.

Dementia:

The Alzheimer's Association recommends screening Medicare beneficiaries for dementia each year through a combination of history-taking and a brief objective cognitive assessment. Patients with a positive screen should receive a full dementia evaluation to determine the appropriate diagnosis. However, based on the documents provided, UHG has taught its providers that dementia can generally be diagnosed with just two of the following: "abnormal [objective cognitive assessment], disorientation on [physical exam], memory problems on [review of systems], and loss of independence with [activities of daily living]."

In 2014, CMS removed dementia from its list of codes (CMS-HCC), partly due to concerns over upcoding. After CMS reintroduced the code in 2020, researchers found that "annual incident dementia diagnosis rates in MA increased by 11.5%" relative to traditional Medicare.

Past Grassley Actions:

Grassley chaired the Senate Finance Committee in 2003 when MA became law. Since then, he has been both an advocate and a watchdog for the MA program. Since 2015, he has pressed CMS and the Department of Justice to recover improper payments made to MAOs like UnitedHealth Group.

Last February, Grassley wrote to UnitedHealth, demanding detailed information on the company's Medicare billing practices.

Grassley authored the 1986 legislation that strengthened the False Claims Act, which has recouped more than $78 billion for taxpayers since becoming law. In 2011, Benjamin Poehling, a former finance director at UHG, filed an ongoing suit under the False Claims Act (FCA), alleging when UHG used chart reviews and in-home HRAs to find opportunities to add codes, the company simultaneously ignored or failed to look for evidently inaccurate codes that were included in billing statements from healthcare providers. UHG would then allegedly submit these inaccurate codes to CMS to garner higher risk scores and MA payments.

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