The nation’s two largest Medicare Advantage (MA) insurers say they support reforming the federal program to rein in certain billing practices.
Just hours after senators added MA overpayment reform to their list of priorities in the One Big Beautiful Bill moving through Congress, the Wall Street Journal reported Humana has spent the last six months developing proposals to limit payments to insurers from at-home health risk assessments (HRAs).
Diagnoses recorded only during at-home visits, and not also in other settings, should not result in payments to health plans, Humana shared with Congressional staffers. Additionally, the insurer would back a ban on payments from medical chart diagnoses when they aren’t connected to “specific medical encounters.”
UnitedHealth Group then posted a statement saying they back “policies that hold in-home clinical visits to the highest standard.”
The company rolled out a list of policies it would support. They include: requiring enrollees to receive timely follow-up care after an in-home diagnosis, making health plans connect enrollees to a care navigation pathway, improved reporting and transparency and introducing annual audits on HRAs.
UnitedHealthcare and Humana cover about half of MA enrollees nationwide. Humana has also been a supporter of the Improving Seniors’ Timely Access to Care Act, allowing a smoother prior authorization process for providers and patients.
Insurance trade group America’s Health Insurance Plans has previously supported changes to HRAs, including mandating they fulfill the elements of a Medicare-covered annual wellness visit, a spokesperson told Fierce Healthcare.
“Health plans support greater adoption and standardization of best practices related to HRAs,” said Tina Stow, executive vice president of AHIP.
The Blue Cross Blue Shield Association stressed the importance of the MA program to Fierce Healthcare, stating the company would continue to "partner with congressional leaders and the Trump Administration."
A federal government watchdog report last year found $7.5 billion in risk-adjusted payments was pocketed by MA health plans when diagnoses were only found on chart reviews. No follow-up visits or tests were provided to 1.7 million enrollees.
The Department of Justice is investigating UnitedHealth Group for upcoding practices and separately on antitrust matters.
Reconciliation bill latest
Touching the Medicare programs was thought to be off-limits for Republicans in any upcoming reconciliation legislation, but there is bipartisan support for curtailing the MA program and rooting out waste.
Lawmakers would like to find more spending cuts to appease the hawkish wing of the party, and the antitrust wing of the Senate may support provisions to cut the country’s biggest insurers down a peg.
Still, the bill could be on unstable ground following a public feud between President Donald Trump and former advisor Elon Musk that erupted on Thursday.
Musk, in a barrage of posts on X, opposed the legislation and said Republicans supporting the bill should be voted out of office. He successfully derailed an end-of-the-year bill last year, which would’ve seen passage of pharmacy benefit manager reform, among other priorities.
New polling from KFF show seven in 10 adults are worried about cuts to Medicaid, and 45% of Affordable Care Act marketplace (another program which would be impacted by the bill’s passage) enrollees identify as Republicans.
The topic of Medicaid cuts is proving to be a landmine for some Republicans. Centers for Medicare and Medicaid Services Administrator Mehmet Oz, M.D., said able-bodied adults should be forced to work or volunteer if they are to receive these health benefits.
“Go out there, do entry-level jobs, get into the workforce, prove that you matter,” he said. “Get agency into your own life.”
When told in a town hall by angry constituents that Medicaid cuts would lead to deaths, Sen. Joni Ernst, R-IA cast aside those concerns.
"Well, we all are going to die,” she said.
Editor's Note: This story has been updated to remove an out-of-context quote.