Ask the Advisor: May 2016

Ask the Advisor: May 2016

Are These Home Nurse Visits Legit?

Q: I’m helping my brother who has cognitive problems. He’s enrolled in a Humana Medicare Advantage plan that covers prescription drugs in addition to providing hospital and doctor benefits. The plan seems OK, but I’m annoyed by numerous (often weekly) phone calls from the plan asking for permission to send out a visiting nurse. They say the visit is provided at no charge to get his blood pressure, and a physical. That sounds good, but my brother doesn’t want strangers coming to his home, and I’m getting suspicious. Is this request legitimate?

A: According to the Center for Public Integrity, one of the nation’s oldest nonpartisan investigative news services, home visits have risen sharply at many Medicare Advantage health plans. While visiting nurses and doctors don’t offer any treatment during these visits, they do report exam findings to the patient’s primary care doctor. Insurers say the free annual physicals offer a new benefit to help certain health plan enrollees stay fit and in their homes as long as possible. But critics, including some Members of Congress, are concerned the visits may be padding Medicare’s bill.

The “house calls” can be money-makers for health plans when they document medical problems like complications from diabetes or heart trouble. Health plans profit because Medicare pays higher rates for sicker patients using a billing formula based on the patient’s “risk score.” Plans can receive thousands of dollars in higher payments from Medicare even though the insurer incurs no additional costs for covering Medicare services for your brother.

More than 30% of all Medicare beneficiaries were enrolled in Medicare Advantage plans last year. The federal government pays plans a monthly fee to deliver all their healthcare needs — a fee that’s based for the most part on risk scores. In 2015 plans like Humana received on average about $9,900 per person for the year. According to government estimates, Medicare made nearly $70 billion in improper payments to Medicare Advantage plans from 2008 through 2013, mostly due to inflated risk scores.

With more than 17 million Medicare Advantage enrollees, the Centers for Medicare and Medicaid Services hasn’t been able to ensure that their risk scores are accurate. When CMS has checked, nearly one - third of the scores were too high.  “Given the size of Medicare Advantage, even a small error can add up to billions in overpayments,” says TSCL Executive Director Shannon Benton. “TSCL believes that home visits should be focused on providing better care to the patient, not boosting health plan profits.”

You might better be able to help your brother by reminding him of doctor visits and seeing that he gets to appointments. You can also help by monitoring his care plan, and making sure he understands how and when to take prescriptions and any other forms of therapy.

Sources: “Home Is Where The Money Is For Medicare Advantage Plans,” Fred Schulte, Center For Public Integrity, June 10, 2014. “Medicare Advantage 2016 Data Spotlight: Overview of Plan Changes,” Kaiser Family Foundation, December 2015. 2015 Medicare Trustees Report, July 22, 2015.