Wait – what? Medicare pays $50 billion a year for patients who received no care?

Suppose someone told you that you had diabetes? Or HIV. How about cataracts – AFTER you’d already had cataract surgery by a top ranked surgeon? Now suppose I tell you these diagnoses were NOT made by legitimate doctors, but by visiting health aides, employed by private insurers? And they were demonstrably wrong? (See link below)

This is a new phenomenon in Medicare Advantage (private insurance). It’s a “home wellness check”. A retiree gets telemarketing calls from his/her insurer. “How would you like to have a health specialist come directly to your home, give you a checkup, and hear about any concerns you have? There’s no out of pocket cost to you . . . ” How could anyone say no?

My mother gets these calls every 3 months. I was with her when she got the last one. She turns to me and asks, “Mona (not my real name) . . . should I let a visiting nurse come over and give me an exam?” I reminded her we already had this conversation. You have 4 doctors already, mom. A general practitioner. A women’s clinic specialist for hormones and uterine problems. A doctor for your spine. Another for your feet (she had bunion surgery last year). And you get a checkup every 6 months by your GP. And they provide all that info to your Medicare Advantage insurer already, who got paid.

So what gives? Why the rush to send a nurse-like stranger to my Mom’s home? Because Medicare will pay “standard fees” to the insurer for this visit. And per the article, in hundreds of thousands of these visits, that stranger diagnosed diseases that didn’t exist, or which had already been cured, and for which no follow-up doctors' care or prescriptions were ever arranged.

Is this another example of defensive medicine? Like a doctor ordering 7 separate blood tests from LabCorp every time you get a checkup? Incompetence? Greed? Can we create a pie chart and show the percentage of each cause, leading to this $50 billion?

This is another one of those problems with no obvious solutions. It would probably be wrong to legislate that these stranger-danger home health visits stop completely. The next time someone’s elderly parent got sick (or passed away) the daughter would be wracked with guilt. “If only we knew. Mom would still be alive”. My mom recently went through this when her dog died of cancer at age 11. A statistically common age and cause for labrador retrievers to check out. My mom believes Buckwheat would still be alive if only she’d done something more. But even the vet said this was never going to happen.

Back to $50 billion in sketchy Medicare billings. One of the insurers slammed the study as “biased”, without challenging the dollar amount. And it’s the government who's paying, so why not be extra careful? But healthcare, like everything else, is a finite resource. Every $50 billion we spend on fake diabetes or cataract diagnoses is $50 billion which won’t treat childhood cancer, or other problems. All those TV ads urging us to open our wallets and save a sick toddler suffering from cancer are real. We need to make donations to the 800 number on the screen because we already spend more on healthcare than any nation on earth, when you add up both the government and private insurance payments.

There’s no easy answer to this. But we’re not going to live forever. If someone ALREADY has 4 doctors, 5 prescriptions, and 2 checkups annually, and the insurer already knows and is paying for these, then there’s something seriously off kilter about constantly calling mom, and cajoling her into allowing a stranger to show up with a stethoscope and blood pressure cuff, no?

I’m just sayin’ . . .

Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated (msn.com)