Investigative Report: $50 Billion in Questionable Medicare Payments

A Wall Street Journal investigation reveals that Medicare paid health insurers approximately $50 billion from 2018 to 2021 for diagnoses that patients did not receive treatment for or that contradicted their doctors' assessments. This includes diagnoses made by insurers that could yield significant profits for them despite a lack of treatment. The investigative team analyzed 1.6 billion Medicare Advantage diagnoses to uncover how private insurers benefit from the program originally designed to provide comprehensive healthcare for seniors and people with disabilities.

The reporters, who had to navigate a complex data-use agreement with the federal government, emphasized the challenges of working with such a vast dataset, which includes extensive information on patient encounters, prescriptions, and more. This investigation brought to light the concerns over how Medicare Advantage, which covers nearly half of Medicare beneficiaries, operates under a system that allows insurers to add diagnoses without direct consultation from the patient's doctor.

The investigation prompted rapid response from government officials and health insurers, highlighting the scrutiny placed on Medicare Advantage plans and the financial implications on taxpayers. Insights from medical professionals supported the findings, as some doctors questioned the validity of these added diagnoses.