Scrutiny on UnitedHealth Group's Medicare Advantage Risk Adjustment Strategies
A recent Senate Judiciary Committee examination, led by Sen. Chuck Grassley, scrutinizes UnitedHealth Group's approach to the Medicare Advantage (MA) program. The report emphasizes the company's profit-driven strategies involving risk adjustment and suggests that Medicare Advantage payments, originally designed for patients with significant health needs, are being maximized through advanced data management and coding practices. This "How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment" report reveals significant insights into the payer's business model within the insurance industry.
The investigation reviewed over 50,000 pages of UnitedHealth's internal documents and discovered an extensive system developed to optimize diagnosis capture. This infrastructure includes in-home health assessments, additional chart reviews, and strategic coding partnerships, which allegedly inflate risk scores for higher federal payouts. Such practices highlight concerns about regulatory compliance, as these efforts may exceed standard documentation, with potential ramifications for both providers and carriers engaged in Medicare Advantage underwriting.
Of particular concern is UnitedHealth's ability to innovate diagnosis codes, even as the Centers for Medicare & Medicaid Services (CMS) tightens oversight by removing specific codes from the adjustment model. The company reportedly markets its coding tools and strategies to competitors, potentially impacting the broader MA insurance market. This situation calls for urgent attention to regulatory compliance requirements, with the report urging that payments to Medicare Advantage Organizations (MAOs) should accurately reflect beneficiaries' true health needs rather than insurers' coding expertise. The CMS proposals for future payment models, targeted for 2027, aim to exclude AI-driven or insurer-added diagnosis codes, reinforcing the need for accurate risk management in the regulatory landscape.