From 2018 to 2021, Medicare Advantage plans received $50 billion for “questionable diagnoses” added by insurers, according to a July 8 Wall Street Journal investigation. The report found higher diagnosis rates for certain conditions among Medicare Advantage beneficiaries compared to traditional Medicare. For example, diabetic cataracts were diagnosed more frequently in Medicare Advantage patients.

Medicare Advantage plans are paid by the federal government based on beneficiary diagnoses. CMS does not reimburse for non-diabetic cataracts but does cover diabetic cataracts, resulting in over $700 million paid between 2018 and 2021. UnitedHealth, the largest Medicare Advantage insurer, disputed the findings, calling them “inaccurate and biased.”

The investigation also found that some beneficiaries had serious diseases listed in their records without corresponding treatment evidence. Only 17% of those with insurer-added HIV diagnoses received treatment, compared to 92% diagnosed by physicians.

This report follows previous investigations into upcoding by Medicare Advantage plans. A 2022 New York Times article claimed insurers incentivized adding diagnoses. Major payers have faced overbilling accusations from whistleblowers, the federal government, or HHS’ Office of Inspector General. MedPAC estimates the federal government will spend $83 billion more on Medicare Advantage beneficiaries than on those in fee-for-service Medicare, with coding intensity in Medicare Advantage expected to be 20% higher in 2024.

Read the Journal’s full report here.