The country’s two largest Medicare Advantage companies are suggesting policies to reform controversial billing practices, including HRAs, marking a significant strategic pivot as congressional leaders seek spending reductions to offset tax cut proposals. Humana has proposed limiting how Medicare Advantage insurance companies can bill the federal government for some diagnoses, while UnitedHealth backs home visit limits that would fundamentally restructure the $460 billion Medicare Advantage program’s payment methodology.
The policy shift emerges following federal scrutiny of Health Risk Assessments (HRAs), with Medicare Advantage plans receiving $4.2 billion in payments for questionable home visits where insurers diagnosed patients with serious conditions, but they sometimes received no follow-up care. The Office of Inspector General’s findings highlight systematic concerns about diagnostic integrity in home-based encounters, particularly when conditions documented during HRAs fail to generate subsequent clinical interventions or care coordination activities.
Humana has told congressional staffers that it will support moves that would curtail billing practices worth billions in extra payments to the industry, representing a paradigm shift for Medicare Advantage risk adjustment models. The insurer’s position specifically targets limiting payments for diagnoses made exclusively during home visits without corresponding physician validation or treatment protocols. This approach addresses fundamental questions about clinical validation hierarchies and whether nurse practitioner-documented conditions during HRAs should generate equivalent risk-adjusted payments as physician-managed diagnoses requiring ongoing therapeutic management.
The strategic implications extend beyond immediate financial adjustments to broader value-based care model integrity. Current risk adjustment methodology allows plans to receive higher capitated payments based on documented member health status, creating systematic incentives for comprehensive diagnostic documentation. However, the controversy centers on whether conditions identified solely through home visits represent genuine clinical entities requiring resource allocation or administrative artifacts designed to optimize reimbursement structures without corresponding care delivery improvements.
UnitedHealth Group and Humana are pushing to increase oversight and limit payments to insurers for in-home clinical assessments, potentially setting a precedent for broader Medicare Advantage payment reform initiatives. Market analysts note this unprecedented alignment between major insurers and federal cost-containment objectives could accelerate regulatory changes affecting the entire Medicare Advantage ecosystem, forcing strategic recalibration toward clinically integrated diagnostic pathways that demonstrate measurable therapeutic value rather than administrative optimization of risk scores.
