UnitedHealth

[Tim Robinson voice] You sure about that?

Jenn Ackerman for STAT

UnitedHealth Group was happy to promote a new audit that said nearly all of the diagnoses recorded for its Medicare Advantage members during home visits (97%) were justified by medical records. But the results are not nearly as clean, or useful, as the company suggests.

The 12-page report — dated June 18, with no listed authors, and not released until last week — walks through the methodology. FTI Consulting, which health insurers have hired to author reports favorable to their causes, made this important disclaimer toward the end: “FTI’s review did not consider visits, and any related documentation, occurring outside of the HouseCalls Program.” 

In other words, UnitedHealth’s audit did not verify whether the codes documented in home visits were validated in follow-up care outside of the home visit. Everything is being graded against UnitedHealth’s trip to the home.

Federal watchdogs and independent researchers have found inappropriate coding practices in Medicare Advantage — specifically from so-called “health risk assessments” conducted in someone’s home. David Meyers of Brown University, one of those researchers who has studied the issue, said the 97% figure is “almost meaningless,” and the audit “seems designed to give [UnitedHealth] the results they want.” 

STAT was not invited to UnitedHealth’s media briefing on the report. In a statement, spokesperson Eric Hausman said: “FTI did not perform a clinical review or clinical validation audit,” consistent with government audits. “FTI’s coding review of HouseCalls focused on whether the diagnosis codes submitted accurately reflected the conditions identified and documented by the provider.”

UnitedHealth CEO Stephen Hemsley and other leaders have promised to be more transparent with the public and shareholders. But the materials released so far only paint a rosy view of the company, with findings that contradict government audits. Meanwhile, UnitedHealth has cut back on important public disclosures and crafted talking points to assuage shareholder unease.

medicare advantage

[DJ Khaled voice] Another one, and another one

Elevance Health was the first company to sue the Centers for Medicare and Medicaid Services over the agency’s updated 2026 star ratings. The next litigants have entered the chat. It’s plausible even more will be coming.

SCAN Health Plan filed its lawsuit last week, saying it was shorted $125 million. SCAN, like Elevance, argued CMS should have calculated its quality scores like it did for Clover Health, the insurer that won a crucial case in May. Alignment Healthcare followed with its own suit late Friday, saying CMS cost the company an extra $50 million.

SCAN also went philosophical, saying the Medicare Advantage star ratings program “went off the rails years ago.” It then quoted the Medicare Payment Advisory Commission — a group that insurers have tried to discredit — saying the program “is ‘overly complex,’ ‘distributes financial rewards inequitably,’ and ‘reports inaccurate information on quality.’”