Finalist: Christopher Weaver, Anna Wilde Mathews, Mark Maremont, Tom McGinty and Andrew Mollica of The Wall Street Journal

Questionable diagnoses of HIV and other maladies triggered extra Medicare Advantage payments; ‘It’s anatomically impossible’

By Christopher Weaver, Tom McGinty, Anna Wilde Mathews and Mark Maremont         Graphics by Andrew Mollica

Gloria Lee was perplexed when the phone calls started coming in from a representative of her Medicare insurer. Could a nurse stop by her Boston home to give her a quick checkup? It was a helpful perk. No cost. In fact, she’d get a $50 gift card.

After several such calls in 2022, Lee agreed. A nurse showed up, checked her over, asked her questions, then diagnosed her with diabetic cataracts.

The finding was good news for Lee’s insurer, a unit of UnitedHealth Group. Medicare pays insurers more for sicker patients. In the case of someone like Lee with diabetic cataracts, up to about $2,700 more a year at that time.

But the retired accountant doesn’t have diabetes, her own doctor later said, let alone the cloudy vision sometimes caused by the disease.

Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021, including outright wrong ones like Lee’s, a Wall Street Journal analysis of billions of Medicare records found.

The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea.

Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two decades to cover more than half of the 67 million seniors and disabled people on Medicare.

Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said. One reason is that insurers can add diagnoses to ones that patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views.

The insurers make new diagnoses after reviewing medical charts, sometimes using artificial intelligence, and sending nurses to visit patients in their homes. They pay doctors for access to patient records, and reward patients who agree to home visits with gift cards and other financial benefits.

Insurers added diabetic cataract diagnoses to 148 patients treated by Dr. Howard Chen, an ophthalmologist in Goodyear, Ariz. He said he saw at most one or two such cases a year.

He said he charges insurers $40 per patient to cover his costs for providing them with medical charts.

“If they are just making stuff up, then why do they even need or want my charts?” said Chen.

In all, Medicare paid insurers about $50 billion for diagnoses added just by insurers in the three years ending in 2021, the Journal’s analysis showed.

plan in 2022.Payment for healthy personMorbid obesity: +$2,370Atrial fibrillation: +$2,541Seizures: +$2,086Chest pain: +$1,280Kidney disease: +$654Prostate cancer: +$1,422Stroke: +$2,180Old-age cataracts: +$0Diabetic cataracts: +$2,863
Patients diagnosed with diabetic cataracts per 10,000 beneficiariesInsurer diagnosed
UnitedHealth
631 patients
Other Medicare Advantage insurers
321
Traditional Medicare
43
Patients diagnosed per 10,000 beneficiaries
Insurer diagnosed
MORBID OBESITYUnitedHealth Group
1,155Other Medicare Advantage insurers
995Traditional Medicare
578HEART FAILURE925713552DEPRESSION418404299EMPHYSEMA335254155
How Medicare pays insurers
The government pays insurers a base rate for each Medicare Advantage member. The insurers are entitled to extra money when their patients are diagnosed with certain conditions that are costly to treat.

Like morbid obesity.

That gives insurers an incentive to search for additional diagnoses. The result is that many of their patients seem sicker, at least on paper.

Medicare pays nothing for some diagnoses.

But insurers can add ones that do pay, even if a patient's treating doctor doesn't agree.

Diabetic cataracts are a complication of diabetes that occur when uncontrolled blood sugar damages the lens of the eye, clouding a person’s vision.

UnitedHealth members were about 15 times as likely to have that diagnosis as the average patient in traditional Medicare, the Journal analysis found. Eye doctors interviewed by the Journal said it was implausible that such a large share of UnitedHealth’s patients could have the relatively rare disease.

The government paid all Medicare Advantage insurers more than $700 million from 2019 to 2021 for diabetic cataracts. Most of the diagnoses were added by insurers.

Medicare Advantage insurers diagnosed all sorts of diseases at high rates.

UnitedHealth and other insurers say they use the home visits and chart reviews to help coordinate patients’ care and ensure accurate diagnoses.

UnitedHealth spokesman Matthew Wiggin said the Journal’s analysis is “inaccurate and biased,” and that Medicare Advantage “provides better health outcomes and more affordable healthcare for millions of seniors” than traditional Medicare.

He said Medicare Advantage plans record diagnoses more completely than doctors treating traditional Medicare patients, and that insurers “identify disease states earlier.” He declined to comment about Lee, citing a healthcare privacy law.

The Journal consulted more than a dozen experts, including academics, actuaries and policy analysts, about its analysis of the Medicare data, who said the methodology was sound.

A spokeswoman for the Centers for Medicare and Medicaid Services, which oversees Medicare, said the agency was making changes that would continue to ensure “taxpayer dollars are appropriately spent.” Medicare Advantage “offers robust and stable options” for beneficiaries, the spokeswoman said.

The Journal reviewed the Medicare data under a research agreement with the federal government. The data doesn’t include patients’ names, but covers details of doctor visits, hospital stays, prescriptions and other care. The Journal identified the patients named in this article through their doctors.

Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

“It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.”

Another 36,000 diabetic cataract patients didn’t receive any medical services or prescription drugs related to diabetes.

No treatment

About 18,000 Medicare Advantage recipients had insurer-driven diagnoses of HIV, the virus that causes AIDS, but weren’t receiving treatment for the virus from doctors, between 2018 and 2021, the data showed. Each HIV diagnosis generates about $3,000 a year in added payments to insurers. 

Everyone with HIV should be on antiretroviral drugs, the only effective treatment, and nearly all Medicare patients whose doctors diagnosed the virus took the drugs. Less than 17% of patients with insurer-driven HIV diagnoses were on them, the Journal found.

“It seems like almost all of those people don’t have HIV,” said Jennifer Kates, HIV policy director at KFF, a health-research nonprofit. “If they did, that would be substandard care at a pretty severe level,” she said.

A spokesman for Humana, the second biggest Medicare Advantage insurer, provided a written statement that said the Journal’s analysis of treatment rates for people with insurer-driven diagnoses “is flawed and misleading.”

The company said that internal data showed its HIV patients who got diagnosed in one way, through home visits, were on antiretroviral treatment at a far higher rate than the Journal found. The Medicare data show about one-third of those Humana patients were on the drugs.

Wiggin, the UnitedHealth spokesman, called the Journal’s analysis flawed because it correlates insurer-driven diagnoses with subsequent medical care.

He said internal company data for 2022 showed a treatment rate for patients UnitedHealth diagnosed with HIV of more than triple what the Journal found. He said the pandemic disrupted care, lowering treatment rates during the period analyzed by the Journal, and that the analysis failed to account for patients who started treatments in future years.

The Medicare data, however, show UnitedHealth’s patients with insurer-driven HIV diagnoses were on the antiretrovirals at low rates even before the pandemic, and hardly any started the drugs in the years after UnitedHealth diagnosed them.

Some of the insurer-driven diagnoses startled patients. Harriet Siskin, a retired customer-service worker, was diagnosed last year with obstructed arteries in her legs by a doctor who visited her house on behalf of her insurer, Humana, which stood to make an extra roughly $2,300 a year from the diagnosis.

“He told me that I may have some sort of artery blockage,” said Siskin, who tested negative a few months later after her regular doctor ordered a full work-up. “He did scare me.”

Humana’s written statement said Siskin’s primary-care doctor also submitted the diagnosis when he treated her following the home visit. It said Humana learned from the Journal that Siskin had later tested negative for the disease, and was working to correct the diagnosis. 

“[W]e strive for complete and accurate clinical information about our members, and to help them get the care they need,” Humana said.

Many patients may never know they have been misdiagnosed by their insurers, and doctors often don’t know when insurers have added diagnoses of their patients.

Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company, the Journal’s analysis showed. UnitedHealth’s net income that year was about $17 billion.

UnitedHealth’s Wiggin said the Journal’s calculations appear accurate. He said the added payments are “not simply earnings for the company,” but help pay for medical care, lower premiums and provide other benefits for Medicare Advantage members.

Humana disputed the Journal’s calculation that the company had received $2.2 billion in 2021 payments from insurer-driven diagnoses, saying that total didn’t reflect chart reviews that lowered payments by removing diagnoses.

Sometimes, insurers didn’t remove potentially outdated diagnoses. The Journal’s analysis found that between 2018 and 2021, nearly 50,000 Medicare Advantage patients completed a course of high-cost drugs that almost always cures hepatitis C, a virus that can cause serious liver damage.

Insurers subsequently told Medicare that more than half of the patients who had received the drug treatment still had hepatitis C in a future year, leading to millions of dollars in extra payments. The diagnoses came from the insurers’ chart reviews and assessments, and from physician claims that insurers didn’t correct.

“They’re totally wrong,” said Douglas Dieterich, director of the Institute for Liver Medicine at Mount Sinai Health System in New York. “Real world evidence is a 99% cure rate.”

Cost concerns

When Congress conceived of the Medicare Advantage program decades ago, the hope was that insurers would make Medicare more efficient. In traditional Medicare, doctors and hospitals get paid for each service they provide, an incentive to provide more. The idea behind Medicare Advantage was to pay private insurers a lump sum to cover all services, giving them an incentive to keep patients healthier.

To protect insurers from the risk of winding up with sicker-than-average patients, the government allowed bigger payments for certain serious health conditions.

Partly because of that, Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report by the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.

Academic researchers and government investigators have raised questions about high rates of insurer-driven diagnoses in Medicare Advantage. In a 2021 report, the inspector general that oversees Medicare found the agency spent billions of dollars based on insurer-driven diagnoses for which patients received no care from doctors.

A 2019 whistleblower lawsuit by a Florida doctor alleged that an insurer submitted inaccurate diagnoses, including that a Medicare Advantage patient’s foot had been amputated when it wasn’t. The insurer, Freedom Health, denied the allegations, and a spokeswoman for Elevance Health, which now owns Freedom, declined to comment.

In September, insurer Cigna Group agreed to pay $172 million to settle civil-fraud allegations by the Justice Department over its Medicare Advantage practices. Cigna admitted to adding diagnoses that weren’t supported by patients’ medical records. Cigna declined to comment.

Government contractors audit Medicare Advantage plans and eventually can recoup payouts for inaccurate diagnoses. An insurance industry trade group, AHIP, said in a written statement that such audits have found Medicare Advantage insurers to be highly accurate.

Medicare administrators are overhauling the list of diseases for which insurers earn higher payments. Some of the most heavily used diagnoses, including diabetic cataracts, will pay less or nothing extra after the changes take full effect in 2026. But new diagnoses, including asthma, were added to the list of conditions warranting extra payments. 

CMS said its changes showed it is a “good steward of taxpayer dollars.”

John Gorman, a former Medicare official and founder of two companies that review records and conduct home visits on behalf of Medicare insurers, doesn’t think the changes will solve the problem. “Any time you base a system like this on diagnosis codes, there’s going to be rampant abuse of the system,” he said. Insurers “will find something else to make up the revenue.”

In 2019, Medicare added dementia to the list of diseases that pay more. That same year, the reported rate of the disease among Medicare Advantage members jumped 7.8% after holding flat for years before that, University of Southern California researchers found.

Vision problems

Cataracts are extremely common in the elderly—pretty much everyone gets them. Diabetes also is common, so it isn’t unusual for old people to have both. But eye doctors say they rarely diagnose cataracts caused by diabetes in old people. It usually isn’t possible to pinpoint the cause, and in any case, the treatment is the same.

For Medicare Advantage insurers, a big difference between the two forms of cataracts is that the government only pays extra for the diabetic ones. 

Some insurers interpreted U.S. guidelines for recording diagnoses in the broadest possible way, labeling patients with diabetes and any kind of cataract with the more lucrative diagnosis. They did it even when doctors said the patients only had the old-age form of the disease or had no diabetic complications at all, the data show.

“If you suspected that it could be connected, they felt they would be justified in connecting it,” said Shannon Decker, a former UnitedHealth employee. “It’s an easy capture.”

UnitedHealth didn’t respond to written questions about its practices for recording diabetic cataract cases.

Over four years, insurers added diabetic-cataract diagnoses to 112 patients of Dr. Stephen McConnell, an ophthalmologist in Brunswick, Ga., the data show. “That’s unbelievable,” said McConnell, who said he had no idea what was happening until informed by the Journal.

Dr. Javier Pérez, an Orlando, Fla.-based eye surgeon, treated hundreds of patients who insurers claimed have diabetic cataracts, the Medicare data show. On average, they were the same age as his old-age cataract patients, about 72.

“Just because you’re diabetic doesn’t mean you have a diabetic cataract,” he said, adding that most almost certainly have old-age cataracts, not ones caused by diabetes. “You can be diabetic and be old,” he said.

Lee, the 70-year-old retired accountant from Boston, recalled that her visit with the nurse practitioner sent by UnitedHealth lasted about 20 minutes. The nurse worked for HouseCalls, a unit of UnitedHealth.

UnitedHealth said that in 2023 three million “gaps in care” were identified during such home visits, which typically last 45 to 60 minutes. It said HouseCalls workers called ambulances 624 times that year after identifying emergencies, and that the visits had a 99% customer-satisfaction rate.

Former employees said UnitedHealth also uses the visits to add diagnoses. A HouseCalls home-visit training manual, which was reviewed by the Journal, describes software used on the laptops that workers carry on home visits. According to the manual, the software offers suggestions about what illness a patient might have—and even adds some automatically to a “diagnosis cart.”

The nurse visiting Lee concluded that her minor cataracts were caused by diabetes that was severe enough to have triggered nerve damage, according to a letter from HouseCalls to her primary care doctor that was reviewed by the Journal. A diabetes test done during the visit was negative, according to the letter.

Lee’s doctor, Nancy Keating, also a professor at Harvard Medical School, said her patient has never had diabetes, let alone complications like diabetic cataracts or nerve damage—a conclusion confirmed by subsequent blood tests.

“It’s all just so wrong,” Keating said.

Lee agrees. “If they’re going to come out and diagnose people with things they don’t have, they shouldn’t get any more money,” she said.

Lee switched to another health plan this year.

Medicare Advantage patients in the last year of life were far more likely to switch to traditional Medicare, shifting costs from insurers

By Anna Wilde Mathews, Christopher Weaver and Tom McGinty

Patricia Greene had spent a month recovering from a devastating stroke when her Medicare Advantage insurer, a unit of UnitedHealth Group, decided to stop paying for her nursing home.

The 85-year-old was so weak and fragile, her son said, that she couldn’t even get herself out of bed. Her family felt she wasn’t ready to leave the facility in New York City’s Queens borough.

So she dropped her UnitedHealth coverage and enrolled in the traditional version of Medicare run directly by the federal government.

That decision saved UnitedHealth tens of thousands of dollars in the months that followed, billing records show, and shifted onto taxpayers the cost of later hospital and nursing home care in what turned out to be the final months of her life.

A Wall Street Journal analysis of Medicare data found a pattern of Medicare Advantage’s sickest patients dropping their privately run coverage just as their health needs soared. Many, like Greene, made the switch after running into problems getting their care covered.

Plans run by the private insurers in the Medicare Advantage system are supposed to offer old and disabled people the same benefits they would get from traditional Medicare. The plans can be a bargain for people because they limit out-of-pocket expenses and often offer extra benefits such as dental care.

As recipients get sicker, though, they may have more difficulty accessing services than people with traditional Medicare. That’s because the insurers actively manage the care, including requiring patients to get approval for certain services and limiting which hospitals and doctors patients can use.

People in the final year of their lives left Medicare Advantage for traditional Medicare at double the rate of other enrollees from 2016 to 2022, the Journal’s analysis found. Those private-plan dropouts—300,075 during that time span—often had long hospital and nursing-home stays after they left, running up large bills that taxpayers, not their former insurers, had to pay.

They cost the federal government an average of $218 a day during that period. That is more than seven times the cost of a typical Medicare recipient, and about twice the cost of other recipients in the last year of their lives. The Journal’s analysis excluded hospice expenses, which traditional Medicare typically covers for all patients.

Medicare Advantage insurers collectively avoided $10 billion in medical costs incurred by the dropouts during that period, the analysis found. If those beneficiaries had stayed in their plans, the government would have paid the insurers about $3.5 billion in premiums, meaning the companies netted more than $6 billion in savings during that period.

“These are some of the costliest services, received by some of the costliest patients,” said Claire Ankuda, a physician and researcher at Mount Sinai Hospital in New York who focuses on end-of-life care. “Plans are strongly motivated to reduce the cost of care delivery.”

Medicare Advantage companies said they use Medicare’s standards when they review and approve medical services, and that their setup improves care for their members, including those at the end of life. They said their oversight ensures that customers get safe, appropriate and high-quality care.

A UnitedHealth spokesman, Matthew Wiggin, said the Journal’s analysis focused on just a tiny fraction of the company’s Medicare recipients and that nearly all Medicare Advantage participants are satisfied with the program. He disputed that care denials by insurers played a role in people’s decisions to switch out of Medicare Advantage, saying patients at the end of life might switch coverage for many reasons. 

Medicare experts both inside and outside the federal government have raised concerns about data that shows patients with the biggest medical needs are more likely than others to leave Medicare Advantage plans. A 2021 Government Accountability Office report warned that patients who dropped out of Medicare Advantage in the last year of their lives imposed high costs on the Medicare program and could signal issues with “access to care or the quality of care provided under [Medicare Advantage].”

Medicare Advantage grew out of the idea that the private sector could make the sprawling Medicare program more economical, and private insurers now oversee benefits for more than half of Medicare recipients.

The insurers use some of the same money-saving tactics they use with their non-Medicare customers, such as requiring referrals from primary-care doctors or approvals from insurers for many services, and including only certain hospitals and doctors in their networks. In 2022, Medicare Advantage insurers denied 3.4 million requests for services, according to an analysis by the health-policy nonprofit KFF.

Traditional Medicare requires preapproval for only a small number of services, including surgeries that could be cosmetic—a type of care not covered by the program.

The Medicare data available to the Journal and other researchers doesn’t include details about denials of care by either Medicare Advantage insurers or the traditional government program. Recipients might switch to traditional Medicare for many reasons, including changes in their finances or geographical moves.

In a 2022 report, the inspector general that oversees the Medicare agency analyzed a sample of Medicare Advantage denials and found that 13% of them actually met Medicare coverage rules and likely would have been approved if the patients had been enrolled in government Medicare. The report said some of the most common improperly rejected services were pricey ones sought by patients after they left the hospital—stays at nursing homes and inpatient rehabilitation facilities.

A recent report by the Senate Permanent Subcommittee on Investigations found that Medicare Advantage plans had high denial rates for care in institutions where patients go after hospital stays. For the largest insurers, the rejection rates for such care were between about three and 16 times their denial rates for all services in 2022. In traditional Medicare, hospitals and nursing homes determine who gets such services.

Switching to traditional Medicare gives some patients another path. The Journal’s analysis found nearly 20% of people near the end of life who left Medicare Advantage received nursing-home services within a week of landing back in traditional Medicare. By comparison, 3.9% of all traditional Medicare patients near the end of life used those services in a typical week.

A spokeswoman for the Centers for Medicare and Medicaid Services said it “has taken many steps to address the use of prior authorization by MA plans and ensure that people with Medicare Advantage have timely access to care.” Any further changes would come through a formal rule, she said.

Covering costs

After a near fatal car wreck that left him with a brain injury, Joseph Smoltz, 78, spent weeks in the hospital. When he moved to a nursing home in New York’s Westchester County, he was still disoriented and struggling to speak, records indicate. In late December of 2020, the nursing home referred him to an inpatient rehabilitation facility that specializes in brain-injury treatment. The request was submitted to his Medicare Advantage insurer, Anthem, for approval.

His son Ken Smoltz, a sales executive in the finance industry, had hired a consultant, Susan Keating, to help advise the family on managing his father’s care. Her advice: Move him to traditional Medicare, which was more likely to cover his needs.

So the elder Smoltz quit Anthem and joined traditional Medicare, as of Jan. 1, 2021. Three days later, his son got an email from the nursing home saying Anthem had rejected the earlier request for a transfer to the rehab facility.

Traditional Medicare would pay, though, so he moved the next day and spent about two months in the inpatient rehab facility. The cost to Medicare: more than $85,000.

Ken Smoltz was left scratching his head about the disparity in coverage. “What you think is the same is just not the same,” he said.

A spokeswoman for Elevance Health, the parent company of Smoltz’s Anthem plan, said it uses prior authorization to ensure “the care our members receive is safe, medically necessary, high value, and appropriate.” Decisions can be appealed, she said.

Medicare Advantage has grown over the past two decades to provide coverage to more than half of the 67 million seniors and disabled people on Medicare. Insurers have lured new customers with plans that promise free dental coverage and eyeglasses, and caps on copays and other out-of-pocket charges. 

Under traditional Medicare, seniors who want to limit such fees need to buy an extra policy called Medigap.

To gauge how well Medicare Advantage serves some of the sickest patients, the Journal looked at enrollment patterns during Medicare participants’ final year of life. The analysis used billions of Medicare records obtained under a research agreement with the federal government. The data doesn’t include patients’ names, and it wasn’t used to identify anyone named in this article.

The Journal found that 5.1% of Medicare Advantage members in the last year of life dropped out to go to traditional Medicare, compared with 2.6% among other Medicare Advantage enrollees. 

The traditional Medicare program spent twice as much a day on hospital care for the end-of-life Medicare Advantage dropouts as it did for other end-of-lifers in traditional Medicare, and more than three times as much on nursing-home care.

To be sure, people near the end of life join Medicare Advantage plans, too, but they do so at a lower rate than the broader population, the Journal’s analysis found.

Patients often choose the private plans because of the perks they see in ads, said David Meyers, an assistant professor at Brown University who has studied Medicare Advantage. “What you don’t know when you are picking a [Medicare Advantage] plan is how long care is going to be delayed because of a prior authorization requirement,” he said.

Medicare Advantage insurers pointed to the majority of members, including those near the end of life, who chose to stay in their plans. UnitedHealth said it was “unfortunate” that the Journal wasn’t more focused on these members.

Leaving a Medicare Advantage plan in the last year of life might add to costs and problems, said Dr. Margaret-Mary Wilson, UnitedHealth’s chief medical officer. “When care is disrupted, you’re going to get rework, you’re going to get inefficiencies.”

‘Freaking out’

Patricia Greene, the stroke victim who left her Medicare Advantage plan, had chosen the UnitedHealth product after seeing an ad on TV, said her son, Michael Greene. He was surprised when nursing home staffers told him UnitedHealth had rejected their recommendation for a longer stay, he said.

“I started freaking out,” recalled the retired New York City paramedic. His mom couldn’t afford to pay for the nursing home, and she didn’t have the strength for tasks like going to the bathroom by herself, he said.

He appealed the UnitedHealth decision twice and lost. He said he didn’t know the Medicare review process allowed him another level of appeal. Instead, he signed up his mother for traditional Medicare and Medicaid, the government program for low-income Americans.

Those government programs covered her continued stay in the nursing home, a hospital admission to treat a urinary-tract infection and other issues, and other expenses. Four months later, she was able to return home to her Queens apartment, where she passed away.

UnitedHealth said 13% of Medicare services are subject to prior authorization requirements under its plans, and less than 1% of all Medicare claims are denied.

For nursing-home authorizations, UnitedHealth’s Dr. Wilson said, the company uses Medicare criteria. The use of such reviews “is really driven by the need to ensure clinical quality and the safety for the people that we serve,” she said. “If a person doesn’t need to be in a hospital or a facility, then they really shouldn’t be there.”

According to the Senate report, UnitedHealth’s denial rate for authorizations of such care rose from 1.4% in 2019 to 12.6% in 2022. UnitedHealth said its denial rate for nursing-home authorizations was 9.2% in 2023, and that the report, which it noted was by the committee’s majority staff, mischaracterizes the Medicare Advantage program and UnitedHealth’s clinical practices.

Medicare rules make it complicated to switch out of Medicare Advantage. Most Medicare enrollees can adjust their coverage only once a year, to take effect on Jan. 1. Enrollees who are in nursing homes get a special window to change plans. Still, their new coverage doesn’t take effect until the start of the following month.

Tatiana Fassieux, a Medicare expert at the nonprofit California Health Advocates, navigated a transition for her own mother in 2022. Her mom, Agnes Smirnoff, had been in a Los Angeles-area nursing home for 19 days, recovering from a broken femur, when her Blue Shield of California Medicare Advantage plan said that June that she needed to go home. 

Fassieux felt that her mother, then 96, still needed nursing-home care. Fassieux won three appeals, forcing Blue Shield to pay into early July.

Eventually, she lost. Fassieux decided to switch her mother to traditional Medicare, but she had to stay in the Medicare Advantage plan until the start of the next month.

Fassieux’s family spent more than $14,000 of their own money to keep her mother in the nursing home during her last few weeks in Medicare Advantage. That Aug. 1, traditional Medicare kicked in and covered two more months of nursing-home care, costing the government about $55,000.

A Blue Shield spokesman said its authorization decisions are governed by Medicare criteria, and can be appealed. “We recognize that many end-of-life cases are extremely complex,” he said, adding that the company is committed to providing seniors with access to care.

Complicated choices

Many patients feel they can’t afford to leave Medicare Advantage plans because their plans limit copays and other out-of-pocket charges, while traditional Medicare doesn’t.

Many enrollees in regular Medicare cover those costs through supplemental Medigap plans or Medicaid. Those who sign up for Medicare when they turn 65 have a window to buy Medigap coverage at relatively low rates. But when people switch to traditional Medicare later, Medigap companies can charge far more for those with pre-existing conditions—or reject them altogether.  

The Journal’s analysis found that people in the last year of life who had access to that type of additional coverage—either Medicaid or Medigap policies—dropped out of Medicare Advantage at far higher rates.

That might help explain why certain Medicare Advantage insurers had among the highest dropout rates in the Journal’s analysis. At Healthfirst, an insurer in New York, where state law makes Medigap policies far more accessible, 12% of members near the end of life left for traditional Medicare, more than double the rate of the broader industry. 

At Molina Healthcare, an insurer focused on patients with both Medicare and Medicaid, 16% of members quit their plan in the last year of life, the highest rate in the country among large insurers.

Both insurers pointed to the large share of their Medicare members who are also enrolled in Medicaid. A Molina spokesman said that, based on its membership mix, “the statistics are well within our expectations and in line with industry norms.”

A spokeswoman for Healthfirst, a nonprofit, said its overall disenrollment rate, for all members, was half the national average last year. “We take many steps to make it easier for members to get access to care,” she said.

Janet Burch, an 80-year-old retired teacher in Clifton, Texas, had a stroke in February. She was airlifted from the local hospital to one in Waco, where she spent eight days, including some in the intensive-care unit.

The hospital referred her to a nursing home, but UnitedHealth, her Medicare Advantage insurer, refused to cover it. Burch’s family was angry. “They just abandon you if you’re sick,” said her sister, Susan Orr.

The insurer decided Burch didn’t need nursing-home services, based partly on records showing she could walk “100 feet with a walker and light-touch support,” according to a document later sent to the family.

A video taken by one of Burch’s sisters near the end of her hospital stay showed the patient shuffling hesitantly with a walker, while an attendant kept a grip on a belt strapped around her waist.

Terrified that the frail, often-disoriented Burch would fall and hurt herself, Orr and two other siblings took turns staying at her house. UnitedHealth paid for some care in her home, including visits by a health aide and a physical therapist, which Orr said had little effect on her condition.

The family looked into moving Burch to traditional Medicare, but an insurance agent warned that a Medigap policy would be costly. In Texas, patients with pre-existing conditions can be charged more for Medigap coverage or rejected outright. Also, Burch likely would have needed to wait until the start of 2025.

The family ended up tapping her savings to pay for a local nursing home, where she could get frequent physical therapy. Burch paid about $4,900 for approximately three weeks, and her condition improved, Orr said.

Burch moved to an assisted-living apartment and walks without a walker now, according to her sister.

UnitedHealth said the documentation submitted by Burch’s care team “did not support care in an inpatient setting.” The company said a physician who treated her in the hospital was offered the chance to do a peer-to-peer review and declined.

Burch remains in her Medicare Advantage plan. 

Mark Maremont contributed to this article.

How The Journal Analyzed Medicare Data

The Wall Street Journal analyzed Medicare claims and enrollment records under a research agreement with the federal government. The analysis calculated the rates at which beneficiaries within a year of death switched from Medicare Advantage plans to traditional Medicare. It compared the results to rates for such switches among beneficiaries who lived through a 12-month period ending in June of each year. The analysis, which covers switches from 2016 to 2022, excluded certain less common plan types and patients with severe kidney disease.

To calculate the payments that Medicare Advantage insurers would have received had the people not switched to traditional Medicare, the Journal used patients’ diagnoses and demographic information, along with county-specific maximum payment rates published by the federal Medicare agency.

The Journal’s calculations of traditional Medicare costs exclude payments to hospice providers. Under Medicare rules, traditional Medicare covers most such costs, even for Medicare Advantage recipients.

Graphics accompanying this article are based on the Journal analysis.

The biggest Medicare Advantage insurer presented physicians with checklists of potential diagnoses; ‘I didn’t think I was obese’

By Christopher Weaver, Anna Wilde Mathews and Tom McGinty

Like most doctors, Nicholas Jones prefers to diagnose patients after examining them. When he worked for UnitedHealth Group, though, the company frequently prepared him a checklist of potential diagnoses before he ever laid eyes on them.

UnitedHealth only did that with the Eugene, Ore., family physician’s Medicare Advantage recipients, he said, and its software wouldn’t let him move on to his next patient until he weighed in on each diagnosis.

The diagnoses were often irrelevant or wrong, Jones said. UnitedHealth sometimes suggested a hormonal condition, secondary hyperaldosteronism, that was so obscure Jones had to turn to Google for help. “I needed to look it up,” he said.

The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.

More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.

Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans, according to the Journal’s analysis of Medicare data between 2019 and 2022.

Sickness scores for those UnitedHealth patients increased 55%, on average, in their first year in the plans, the analysis showed. That increase was roughly equivalent to every patient getting newly diagnosed with HIV, the virus that causes AIDS, and breast cancer, the analysis showed.

That far outpaced the 7% year-over-year rise in the sickness scores of patients who stayed in traditional Medicare, according to the analysis. Across Medicare Advantage plans run by all insurers, including UnitedHealth, scores for all newly enrolled patients rose by 30% in the first year.

A spokesman for UnitedHealth said in a written statement that the company’s practices lead to “more accurate diagnoses, greater availability of care and better health outcomes and prevention, including less hospitalization, more cancer screenings and better chronic disease management.” The company’s approach, he said, helped to avert more serious health problems later, and to achieve Medicare Advantage’s goals of improving quality and reducing costs.

In a series of articles this year, the Journal has examined the practices of Medicare Advantage companies, including UnitedHealth, the largest. Among other things, the articles showed how diagnoses added by insurers increased payments from the government.

The killing earlier this month of Brian Thompson, chief executive of UnitedHealth’s insurance division, triggered widespread public venting about some of the practices of health insurers. Police said the suspect left a note saying he was taking action against the healthcare industry. UnitedHealth has said that neither the suspected gunman nor his parents were covered by the company.

In its written statement, UnitedHealth said Medicare’s system of paying for diagnoses was developed by the government, not any one insurer, “to help ensure fair and accurate payments.”

UnitedHealth and other Medicare Advantage insurers have said higher sickness scores among their patients reflect a sicker population with greater medical needs. UnitedHealth has said the diagnoses it submits are accurate, and that it detects diseases sooner, benefiting patients.

Jones, the Oregon doctor, said UnitedHealth didn’t suggest diagnoses for patients he treated outside Medicare Advantage, where it doesn’t pay.

Traditional Medicare patients treated by UnitedHealth doctors had much lower sickness scores, the Journal’s analysis showed.

A case of hyperaldosteronism—the obscure hormonal condition that sometimes appeared on Jones’s checklists—could trigger about $2,000 a year in Medicare Advantage payments during the period the Journal studied. The Journal’s analysis showed that doctors who didn’t work for UnitedHealth seldom diagnosed that condition, which involves elevated levels of a hormone linked to high blood pressure.

Jones said he quit UnitedHealth in 2023 to start his own practice.

UnitedHealth has acquired dozens of medical groups over the past decade-and-a half. Its Optum unit now employs about 10,000 physicians, its top executive has said, making it one of the nation’s largest employers of doctors. It contracts with tens of thousands more. No other national insurer has acquired and hired doctors on that scale.

Other insurers have made more limited investments. Humana runs a network of primary-care centers under the CenterWell brand, and last year Aetna parent CVS Health purchased Oak Street Health, a clinic operator that specializes in treating seniors.

Patients of the medical groups operated by UnitedHealth have unusually high sickness scores compared with those of other doctors’ practices, the Journal’s analysis found.

UnitedHealth’s doctors, in addition to treating those in the company’s Medicare Advantage plans, treat people covered by other insurers and traditional Medicare.

Patients who both saw UnitedHealth doctors and were enrolled in UnitedHealth plans had the highest average sickness scores in the Journal’s analysis of claims from 2019 to 2022. Those higher sickness scores triggered about $4.6 billion more in Medicare payments than UnitedHealth would have received if those patients’ scores had been in line with the average for the company’s other Medicare Advantage patients.

“The system is not primarily about taking care of the patient,” said Dr. Emilie Scott, who worked for a UnitedHealth-owned practice in California before leaving in 2016. “It’s, how do you get the money to flow?”

The Journal analysis is based on billions of Medicare records obtained under a research agreement with the federal government. The Journal also examined internal documents from medical practices owned by or under contract with UnitedHealth.

UnitedHealth said its sickness scores trend higher partly because its plans “serve some of the sickest and most vulnerable populations,” and that research showed under-diagnosing in traditional Medicare led to some of the differences in sickness scores between the two parts of the program. The company said it had performed well in Medicare’s audits of the accuracy of diagnoses it submits for payment.

The company said revenue accrued from additional diagnoses “are not simply earnings for the company but are instead used to invest in medical benefits” and reduce out-of-pocket costs for members, among other things. It has said that its insurance unit, UnitedHealthcare, operates separately from its Optum health-services arm.

A spokeswoman for the Centers for Medicare and Medicaid Services declined to comment on the Journal’s analysis, but said the agency is studying relationships between Medicare Advantage insurers and medical providers. She said Medicare Advantage insurers are required to ensure the accuracy of diagnoses they submit, and that the agency had overhauled the list of diagnoses that trigger extra payments.

The Journal reported in July that Medicare Advantage insurers added diagnoses to patients’ health records that no doctor treated. The insurers collected $50 billion in payments from 2019 through 2021 for those diagnoses, the Journal reported.

Recording diagnoses

When Dr. Naysha Isom started working at a UnitedHealth medical group in the Las Vegas area in 2019, she said, she got two days of training on how to record diagnoses. At the training, a UnitedHealth employee suggested that Isom, who had practiced for more than a decade, should consider diagnoses she had never made before.

Isom said she was told that signs of bruising could be recorded as senile purpura, a condition that generated payments in Medicare Advantage but generally didn’t require treatment. Isom saw no point, since the finding didn’t change patients’ care: “OK, wear some sunscreen. Maybe stop bumping the wall.”

After she decided not to diagnose peripheral artery disease, a narrowing of blood vessels, based on a screening test she distrusted, she said, a supervisor pressed her to reconsider. UnitedHealth didn’t require her to make diagnoses, she said.

“You’re just encouraged to, because obviously, if you don’t, they come bothering you,” said Isom, who left UnitedHealth to start her own practice in 2022.

UnitedHealth’s doctors in the Journal’s analysis diagnosed the bruising condition, which triggered extra payments of about $1,900 a year at the time, 28 times more often with patients in UnitedHealth Medicare Advantage plans than those in traditional Medicare. 

The bruising condition, senile purpura, “is a completely benign condition” for patients, said G. Michael Harper, a geriatrician at the University of California, San Francisco. “There’s nothing you have to do for them.”

An internal presentation to doctors at a UnitedHealth-owned medical group in Southern California, reviewed by the Journal, listed doctors and the average Medicare sickness score for their patients. Doctors with the highest averages were highlighted in green, and those with the lowest, in red. The presentation showed that as of July 2022, the average sickness score among those practices’ patients was 55% higher than the average among traditional Medicare recipients.

Under Medicare rules, each condition that triggers extra payments has to be diagnosed annually. UnitedHealth doctors said patients whose records showed past diagnoses that hadn’t been re-documented were frequently called in for office visits, and the company’s software would spool out lists of potential diagnoses.

The list UnitedHealth sent one doctor included a potential diagnosis of a lower-leg amputation, citing prior records, even though the patient wasn’t missing a limb. The company told another doctor it suspected a patient had heart failure “based on prevalence of this condition in our patient population.”

Jones, the former UnitedHealth doctor in Oregon, said the suggestions included diagnoses based on scant evidence, such as long-term insulin use for patients who had received the drug only once during a long-ago hospital stay. For patients regularly taking aspirin, he said, the technology would propose a clotting disorder.

To finish a visit, he had to check a box to confirm or rule out each possible diagnosis—or defer it for later. At first, he said, the checklists were optional, but then they became mandatory. He usually rejected the hyperaldosteronism diagnoses, he said, if he didn’t see any testing or treatment for the condition.

The design of the system, he said, could lead to good-faith errors as doctors clicked through all the boxes. “The system is made to have these happy little accidents that end up resulting in a lot of money from taxpayers,” he said.

Bonus pay

A December 2023 compensation plan for one UnitedHealth-owned practice offered doctors bonuses of up to $37.50 a year for each of their Medicare Advantage patients if they confirmed or ruled out more than 90% of the suggested diagnoses. That means a doctor seeing 800 Medicare Advantage patients in a year could see a bonus of as much as $30,000 a year.

Tom Lin, a former UnitedHealth physician in Oregon, said it was easier to say yes than no, particularly with diagnoses that another doctor had previously confirmed and placed in the patient record.

“You didn’t have time to rule it out,” he said, given the volume of patients each day. He said he did his best to remove from patients’ charts diagnoses that he questioned such as secondary hyperaldosteronism, which UnitedHealth often suggested for heart-failure patients, “because I had no idea what the hell they were talking about.”

Shweta Bansal, a nephrologist at UT Health San Antonio who studies that disease, said “the treatment of heart failure is the same” regardless of whether secondary hyperaldosteronism is diagnosed.

UnitedHealth said a company study found that patients of medical providers under its Optum umbrella had better outcomes than patients in traditional Medicare, including an 18% lower risk of inpatient hospital admissions and an 11% lower risk of emergency department visits. The company said its model improved management of chronic diseases, including diabetes.

Like other Medicare Advantage companies, UnitedHealth also contracts with outside doctors in ways that can increase their payments when they diagnose more conditions. That includes arrangements where doctors receive a portion of the Medicare payments insurers get for their patients. Other Medicare Advantage insurers also suggest diagnoses to independent doctors examining their patients.

In some contracts with independent doctors reviewed by the Journal, UnitedHealth linked bonuses to sickness scores and quality ratings derived partly from patient surveys. For patients with sickness scores 20% higher than average and good quality ratings, doctors could get an extra $40 per patient each month, one contract shows. Scores 50% above average and top quality ratings could yield $65 per patient a month. For a doctor with 100 patients covered by the contract, that would amount to a $78,000 annual bonus.

Andy Pasternak, an independent family doctor in Reno, Nev., has lower-than-average sickness scores across his practice, records show. He said he gets a per-patient bonus of $2 a month, or $2,256 annually, for the 94 Medicare Advantage patients covered by his contract with UnitedHealth. 

Pasternak said UnitedHealth offered to send nurses to visit those patients to diagnose them more fully. The company would pay him $250 for each patient their nurses examined, he said.

“That’s more than I get paid for treating my own patients,” he said. He said the focus on diagnosing has soured him on Medicare Advantage, and made him grateful when patients younger than 65 come to his office.

One UnitedHealth document reviewed by the Journal projected Pasternak could receive as much as $23,250 a year in such payments. A UnitedHealth executive in his area told him in an email his practice also would benefit from any additional diagnoses made by the nurse.

Valerie O’Meara, a former UnitedHealth nurse practitioner, said she never provided treatment for the patients she saw in doctors’ offices in Washington state. “Your job is finding diagnoses, that was clear as a bell,” she said. “I was like, am I finding all these things that the doctors who are taking care of these people didn’t find?”

She said a Minnesota-based UnitedHealth manager urged her to make new diagnoses beyond what doctors had treated. Patients were often confused, she said, about why she, not their own doctor, was examining them. “They don’t tell the patient, the nurse needs to see you to make sure your high-scoring medical problems are checked off this year.”

Suspicious patient

Chris Henretta, a UnitedHealth Medicare Advantage plan member who lives in The Villages, a retirement community in central Florida, was suspicious when his primary-care doctor diagnosed him as morbidly obese during his annual exam in October.

He is a lifelong weightlifter, plays water volleyball five times a week and has an athletic build.

“I told her I didn’t think I was obese,” Henretta said. When she recorded morbid obesity anyway, he said, he began to “suspect my doctor may have a financial incentive to portray people as higher risk.”

The diagnosis can trigger payments of about $2,400 a year to Medicare Advantage insurers.

A widely used measure to diagnose obesity, body-mass index, has been criticized for sometimes mischaracterizing muscular people as overweight. Henretta’s medical record shows that even by that standard, he didn’t qualify as morbidly obese. His BMI was 32.3 at the time of his October visit, nearly three points below the minimum threshold for morbid obesity.

Henretta’s doctor at The Villages Health, a clinic that contracts with UnitedHealth, also diagnosed him with qualitative platelet disorder, a condition that affects blood clotting.

Henretta said his doctor added the diagnosis after he agreed that his blood seemed to clot slightly more slowly after he started taking baby aspirin several years earlier. His doctor had recommended the baby aspirin after he was diagnosed, in 2021, with aortic atherosclerosis—which could trigger Medicare payments of about $2,700 a year at the time.

Dr. Rachel Bercovitz, a hematologist and professor at Northwestern University’s medical school, said aspirin inhibits platelet function, so Henretta’s doctor is “diagnosing the intended effect of the medication” as a separate disease.

A qualitative platelet disorder diagnosis can trigger extra payments of about $2,000 a year to insurers.

The Villages Health, its top executives and Henretta’s doctor didn’t respond to phone calls and emails requesting comment.

Dr. Coleen Madigan, who worked for a UnitedHealth medical practice in Texas for a little over a year before leaving in 2020, said one of her patients there didn’t know what she was talking about when she asked when he had been diagnosed with chronic obstructive pulmonary disease, and got upset when she told him his chart included the illness.

The patient was a smoker who had bronchitis in the past, but he had never been tested to confirm COPD, Madigan said. She added a note to his record saying there wasn’t documentation to support the lung disease diagnosis, she said, but it was difficult to remove completely.

During her time at UnitedHealth, Madigan, now mostly retired, said she felt “an insidious pressure” to document diagnoses. “It distracts you from focusing on the patient.”

Mark Maremont contributed to this article.

Taxpayers paid for their care at the VA—and for Medicare Advantage coverage that many didn’t use

By Mark Maremont, Christopher Weaver and Tom McGinty

Bruce Kitt is one of the Medicare Advantage industry’s most lucrative customers.

The federal government pays his private Medicare Advantage insurer thousands of dollars a year to cover the cost of doctor visits, hospitalizations and other medical care that the 74-year-old retired aircraft mechanic might need.

But Kitt, an Air Force veteran who served in Thailand during the Vietnam War, gets almost all of his healthcare outside the Medicare system, through the Minneapolis VA Medical Center. The taxpayer-funded Department of Veterans Affairs health system provides low-cost or free care to Kitt and about nine million other qualifying veterans.

Kitt’s Medicare Advantage insurer, an affiliate of CVS Health’s Aetna unit, pays for almost nothing other than a $100 monthly cash-like rebate to Kitt as an incentive to keep him on its rolls. The government paid the insurer at least $6,000 to cover him in 2022, the year he joined the plan.

“I don’t think I’ve used my Medicare in years,” said Kitt, who lives in Eden Prairie, Minn. When he needed some eye tests, the VA, not his Medicare Advantage plan, paid for him to go to an outside clinic. “I’m pretty happy with the VA,” he said. “I look at the Medicare plan as a backup.”

A Wall Street Journal analysis of Medicare and VA data found that Medicare Advantage insurers collected billions of dollars a year in premiums to provide medical coverage for about one million veterans like Kitt, even though they go to the VA for some or all of their healthcare needs.

The analysis found the insurers paid far fewer medical bills for those veterans than for typical members. About one in five members of Medicare Advantage plans that enroll lots of veterans didn’t use a single Medicare service in 2021, the Journal found. That compares with 3.4% of members of other Medicare Advantage plans.

The federal government paid insurers an estimated $44 billion from 2018 through 2021 to cover Medicare Advantage-plan members who were also users of VA services, based on average payments for all members of those plans. The VA spent $46 billion on the same group’s medical care, according to VA data reviewed by the Journal. The figures exclude pharmacy costs, which many Medicare Advantage plans focused on veterans don’t cover.

Under the decades-old law that created Medicare, the VA can’t bill Medicare Advantage insurers for services it provides their members. The result is that the federal government sometimes effectively pays twice to cover the health needs of veterans—once in premiums for their Medicare Advantage insurers, then again for the VA to provide actual healthcare services.

Some Medicare Advantage companies are openly chasing veterans, rebranding their insurance offerings with names like the Humana Honor plan, the Aetna Eagle plan and UnitedHealth Group’s Patriot plan. Almost all the veteran-branded plans offer cash rebates to induce veterans to sign up, a perk that is rare in other Medicare plans.

“These private Medicare Advantage companies are taking large payments from the federal government but avoid paying for healthcare because the VA provides the services,” said Amal Trivedi, a physician at the Providence VA Medical Center and Brown University professor who has studied the VA-Medicare Advantage payment issue.

Insurers said their plans offer veterans more choices for their healthcare, comply with Medicare rules and are priced to account for lower spending on veterans who also use the VA. They said veterans are heavy users of the extra benefits the plans offer, such as dental care, which isn’t reflected in the Journal analysis.

A spokesman for Aetna, which insured Air Force veteran Kitt through its affiliate, said the company is proud to offer Medicare Advantage to veterans and complies with Medicare rules.

The VA encourages veterans to sign up for some form of Medicare, even if they have access to VA health, in part because Medicare gives them the choice of going to a non-VA doctor or hospital. Medicare Advantage plans are attractive to many veterans because they offer perks that go beyond what Medicare requires, ranging from the dental benefits to gym memberships.

Medicare Advantage, the privatized form of the federal health program for seniors and disabled people, was expanded about two decades ago in an effort to deliver care more efficiently. The insurers get paid a lump sum every month to cover members’ healthcare, with higher payments for patients diagnosed with more serious health conditions. The private plans now cover more than half of Medicare recipients.

The program has proved popular, but also has cost taxpayers far more than traditional Medicare coverage, according to the Medicare Payment Advisory Commission, a congressional agency.

One reason, the Journal has reported previously, is insurance company practices that result in higher payments from the government, such as diagnosing patients with conditions that no doctor had ever treated but that entitle insurers to billions of dollars in extra payments.

To analyze how Medicare Advantage insurers can profit from veterans, the Journal examined 93 plans where a majority of members were veterans who used VA health services. The plans, covering about 200,000 people in 2021, were identified using VA data provided by Trivedi and his team at Brown and the Providence VA.

The Journal then used Medicare data to examine how much the insurers were paid by the government for each plan, compared with how many medical services their members used.

Under Medicare rules, the government payments are supposed to be based on the amount insurers expect to spend on members’ health expenses, plus an allowance for overhead and a modest profit. Each year, insurers propose pricing for their plans, which Medicare must approve.

The Journal’s analysis suggests that the government is overpaying insurers for veterans’ coverage.

The insurers charged the government a total of about $1.7 billion in 2021 for the veteran-majority plans. On a per-member basis, that came to 77% as much as other plans in the same geographic areas. The lower price, insurers say, reflects the lower cost of caring for veterans who are getting a portion of their care from the VA.

But members of the veteran-majority plans used far fewer medical services than members of the other plans: They had 53% as many surgeries, 50% as many doctor visits and 55% as many radiology scans. They also spent fewer days in the hospital—about 72% as many as members of other plans.

A Medicare spokeswoman said insurers’ prices “are expected to reflect the lower revenue need, given that veterans may access the VA for some services.”

A spokesman for Humana, the leader in veteran-focused Medicare Advantage plans, said veterans “have earned the right to choose their healthcare coverage” and that they benefit from the additional options. The spokesman, Kevin Smith, said Humana’s analysis of its own plans, which used a different methodology, “yields higher veteran utilization of Medicare Advantage benefits” than the Journal’s analysis. He also said the Journal’s analysis doesn’t account for veterans’ use of certain additional benefits offered by its plans, such as dental and vision coverage.

The Medicare data was reviewed by the Journal under a research agreement with the federal government. The data don’t include patients’ names, but cover details of doctor visits, hospital stays and other care. The Journal didn’t use the data to identify patients named in this article.

While members of veteran-majority plans used few Medicare-covered services, many were heavy users of VA health services, according to the VA data provided by Trivedi. The VA system spent an average of about $17,000 caring for veterans in those plans in 2021, not including pharmacy spending, about 30% more than the typical veteran.  

Total spending on all Medicare Advantage members amounted to 17% of the VA’s $100 billion healthcare expenditures in 2021, the VA data show.

That’s a big dent for an agency that has struggled in recent years to meet demand, partly because of an influx of veterans seeking care after Congress expanded eligibility for VA health benefits. VA officials have asked Congress for extra funding to cover medical costs in the current fiscal year. Congress so far hasn’t acted on the request. 

Richard A. Stone, a retired Army major general and physician who ran the VA health system under parts of the Obama, Trump and Biden administrations, said top VA officials have long been aware that Medicare Advantage insurers were getting paid by the government to cover veterans who were receiving some or all of their care at the VA. They never addressed it, he said, because they worried that a fix lacked political support.

There is a simple solution, he said: Congress could allow the VA to bill the Medicare Advantage insurers.

When the VA treats younger veterans who have private insurance through their employers or the ACA marketplace, rather than Medicare, the agency sends a bill to their insurers for any care not connected to their military service. The VA collected $3.7 billion in 2024 from non-Medicare insurers from such claims, VA budget figures show.

But the VA has been prohibited from billing Medicare—including Medicare Advantage insurers—since the program was created in 1965, decades before the private plans emerged as a dominant force in Medicare. When it comes to traditional Medicare patients, that doesn’t matter much because the government only pays once for their care, whether it’s through Medicare or the VA.

“Nobody ever envisioned in 1965 a third party entity, like UnitedHealth or Humana, actually running the Medicare program on behalf of the federal government,” said Stone. “Bringing this to light will have huge value in the evolution of the Medicare program and for the health of veterans.”

VA press secretary Terrence Hayes said in an email: “We will continue our efforts to collect all applicable revenue as part of our commitment to being good stewards of taxpayer funds and providing veterans, caregivers, family members, and survivors with the care and benefits they deserve.”

The Humana spokesman said the company strongly supports increased coordination between Medicare and the VA, “given the aging population of veterans and increasing complexity of their healthcare needs.” 

The VA generally receives high marks for delivering quality care. In addition to running hospitals and outpatient centers, the VA covers billions of dollars worth of care outside its own system because Congress requires it foot the bill when its own facilities can’t provide timely or convenient care. That means Medicare Advantage plans often avoid costs for veterans even when they go to private hospitals or doctors.

Academic studies have identified the duplicate-payment issue, including a 2012 paper by Brown’s Trivedi and others. Researchers at the University of Pennsylvania in a 2020 study found the VA was picking up the tab for thousands of costly heart surgeries on Medicare Advantage members. A Harvard University-led research report in November found Medicare paid insurers $1.3 billion in 2020 for veterans who used no Medicare services.

The extra benefits offered by many Medicare Advantage plans make them a “no-brainer” for a veteran who gets the majority of medical care from the VA, said Tim Jopp, an insurance broker in Waconia, Minn., who sells a lot of the veteran plans. 

Perks in the veteran-focused plans often include the cash-like rebates that insurers pay to encourage people to sign up and stay in. The rebates—discounts on Medicare premiums—show up as higher monthly payments in recipients’ Social Security checks.

As of this year, 88% of plans marketed to veterans paid such rebates, compared with 11.7% of other plans. On average, members of veteran-branded plans were eligible for about $1,000 a year in such rebates, a Journal analysis of benefit and enrollment data shows.

The Humana spokesman said many veteran-focused plans offer more extra benefits than other Medicare Advantage plans because they don’t usually cover pharmacy benefits. Plans that cover drugs typically spend some of their revenue available for extra benefits to subsidize pharmacy costs, he said.

Humana, based in Louisville, Ky., covered 79% of all Medicare members who were in veteran-majority plans in 2021, the Journal analysis shows.

The company rebranded some of its veteran-heavy plans as Honor plans in 2020, and told investors its Honor plans’ membership grew by 80% the next year. 

UnitedHealth Group, which launched its Patriot-branded plans aimed at veterans in 2021, markets some through senior advocacy group AARP.

Under Medicare Advantage rules, insurers are entitled to extra payments from the government for patients with certain diagnoses. When customers go straight to the VA for care, though, their insurers might not be aware of such payment-boosting diagnoses.

Another way for insurers to collect diagnoses that make them eligible for extra payments, including for conditions being treated only by the VA, is by sending nurses to visit members at their homes to gather health information.

UnitedHealth dispatched nurses to conduct home visits with members of its veteran-majority plans about 20% more frequently than other UnitedHealth Medicare recipients in the same regions, the Journal analysis found.

UnitedHealth said in a written statement that the company’s plans “ensure veterans have access to important additional benefits such as vision, dental, and hearing that complement their VA benefits.” Spokesman Matt Wiggin said veterans are heavy users of such benefits and that the Journal’s analysis was inaccurate because it didn’t account for use of such perks.

Medicare data about plans’ projected spending on optional extra benefits isn’t available for 2021, the year the Journal studied, and Wiggin didn’t provide any for UnitedHealth’s plans. The company didn’t respond to a question about its home visits to veterans.

Navy veteran John Burks, 72, of Wichita, Kan., said he signed up for a Humana Honor plan years ago, but for years never used it, preferring to get his healthcare from the nearby Robert J. Dole VA Medical Center.

“I get basically all of my care at the VA,” Burks said. “I’ve had excellent care there,” he said, despite what he described as sometimes long waits.

That didn’t stop Humana from contacting him frequently, he said, asking to send a nurse for a home visit. “I told them, I just had my annual physical. Why do I need this?” But he allowed them to come three or four times over the years, he recalled.

Burks, who said he enlisted in the Navy while still in high school, comes from a military family. He said his father was twice wounded in the Korean War, and his grandfather fought in World War I.

Over the years, he said, he has been treated at the VA for a chronic lung disease, issues related to asbestos exposure from his Navy service and prostate cancer. He got hearing aids and eyeglasses from the VA, he said, which also paid for him to go to an outside provider for an operation on his nose, which he broke multiple times when he was younger.

He never used Humana’s medical insurance to pay for any of it, he said, until last year, when he fell off a ladder. He stayed in a local hospital and a rehab facility for about six weeks and had multiple surgeries.

The sizable bill was covered by Humana, he said, adding that “Humana has done me excellent, too.”

The Humana spokesman said Burks’s experience shows how Medicare gives veterans the option to get care they need from non-VA doctors and hospitals.

Shortly after being released in a wheelchair, Burks went to the VA emergency room with what he said was a hospital-acquired infection. Then he required six months of physical therapy—paid for by the VA.  

Anna Wilde Mathews contributed to this article.
 

Information gathered from Medicare Advantage patients in their homes triggered extra payments; ‘It made me cringe’

By Anna Wilde Mathews, Christopher Weaver, Tom McGinty and Mark Maremont

Millions of times each year, insurers send nurses into the homes of Medicare recipients to look them over, run tests and ask dozens of questions.

The nurses aren’t there to treat anyone. They are gathering new diagnoses that entitle private Medicare Advantage insurers to collect extra money from the federal government.  

A Wall Street Journal investigation of insurer home visits found the companies pushed nurses to run screening tests and add unusual diagnoses, turning the roughly hourlong stops in patients’ homes into an extra $1,818 per visit, on average, from 2019 to 2021. Those payments added up to about $15 billion during that period, according to a Journal analysis of Medicare data.

Nurse practitioner Shelley Manke, who used to work for the HouseCalls unit of UnitedHealth Group, was part of that small army making home visits. She made a half-dozen or so visits a day, she said in a recent interview.

Part of her routine, she said, was to warm up the big toes of her patients and use a portable testing device to measure how well blood was flowing to their extremities. The insurers were checking for cases of peripheral artery disease, a narrowing of blood vessels. Each new case entitled them to collect an extra $2,500 or so a year at that time.

But Manke didn’t trust the device. She had tried it on herself and had gotten an array of results. When she and other nurses raised concerns with managers, she said, they were told the company believed that data supported the tests and that they needed to keep using the device.

“It made me cringe,” said Manke, who stopped working for HouseCalls in 2022. “I didn’t think the diagnosis should come from us, period, because I didn’t feel we had an adequate test.”

Other nurses interviewed by the Journal said many of the diagnoses that home-visit companies encouraged them to make wouldn’t otherwise have occurred to them, and in many cases were unwarranted.

Last month, the Journal reported that insurers received nearly $50 billion in payments from 2019 to 2021 due to diagnoses they added themselves for conditions that no doctor or hospital treated. Many of the insurer-driven diagnoses were outright wrong or highly questionable, the Journal found. 

The diagnoses added after home visits accounted for about 30% of that total. More than 700,000 peripheral artery disease cases diagnosed only during home visits added $1.8 billion in payments during that period.

In the Medicare Advantage system—conceived as a lower-cost alternative to traditional Medicare—private insurers get paid a lump sum to provide health benefits to about half of the 67 million seniors and disabled people in the federal program. The payments go up when people have certain diseases, giving insurers an incentive to diagnose those conditions.

To find out how insurers use home visits to add diagnoses, the Journal interviewed nurses, patients, home-visit managers and industry executives and reviewed hundreds of pages of internal documents from home-visit companies. They described a system that used nurses, software and audits to generate diagnoses. 

“They do the job with a purpose, and it pays off for the Medicare Advantage plans,” said Francois de Brantes, a former executive at Signify Health, a company that does home visits for insurers. “Identifying the diagnoses, that’s the job.”

Insurers, including UnitedHealth and CVS Health, owner of both Signify and Aetna, said the house calls help patients by, among other things, catching diseases early and making sure people are taking their medicine properly. The insurers said they relay home-visit findings to primary-care doctors.

Nurses who made visits said they felt they were helping some patients with advice about medications, performing needed tests and sometimes reporting health emergencies.

For UnitedHealth, the parent company of the largest Medicare insurer, each home visit was worth about $2,735 in extra Medicare payments during the three years covered by the data, the Journal analysis found. That’s nearly three times the average for all other Medicare Advantage insurers.

UnitedHealth’s chief physician, Dr. Wyatt Decker, attributed the disparity to what he said was UnitedHealth’s sicker patient population and its nurse practitioners being so effective at their jobs.

Sixty percent of UnitedHealth home visits generated at least one new revenue-producing diagnosis of a condition no doctor was treating, the analysis showed. Home visits by Humana, the No. 2 Medicare insurer, did so 39% of the time.

The Journal reviewed Medicare data covering the home visits under a research agreement with the federal government. The data doesn’t include patients’ names, but covers details of doctor visits, hospital stays, prescriptions and other care. 

The home-visit industry has grown in recent years. UnitedHealth’s HouseCalls sent nurse practitioners to the homes of more than 2.7 million people last year. CVS’s Signify performed about 2.6 million home visits in 2023.

Step one is getting Medicare Advantage recipients to agree to a visit, especially patients whom insurers deem most likely to have undiagnosed conditions that would garner extra payments.

Two former managers who oversaw home visits for Humana, and a third who worked for both Humana and Signify, said insurers used an internal scoring system to identify prospects. Under the Medicare Advantage system, diagnoses have to be documented every year to trigger the extra payments, so people who had an earlier home visit that produced extra payments were particularly valued, the managers said.

Insurers also considered other factors, including how likely patients were to agree to a visit, some home-visit executives said.

Call centers bombard Medicare recipients with offers of home visits—in the case of Humana, autodialing them as many as 10 times, according to the former managers. Agents sometimes offered the Medicare recipients incentives such as Walmart gift cards.

A Humana spokesman said the company is committed to accurately identifying patients’ health conditions, and that its home-visit vendors don’t use software to suggest diagnoses for its patients.

Dave Sherwood, a 68-year-old retired accounting executive in Williamsburg, Va., joined a UnitedHealth Medicare Advantage plan last year. Earlier this year, he got a flurry of calls from representatives of the insurer. When he finally answered one, he told them he didn’t want a home visit.

Months later, he started getting the calls again. Finally, he said, he picked one up and told the agent to stop calling.

When patients agree to a visit, home-visit companies send nurse practitioners or, less frequently, doctors or physician assistants. Some are full-time employees, others contractors who get paid around $100 or more per visit. 

At each home, the nurses run through a series of questions covering medical history and medications, as well as doing a physical assessment and some basic testing.

In the HouseCalls system, nurses feed the information into a laptop or tablet, and the software suggests diagnoses. They automatically appear in a “diagnosis cart” on the side of the screen, according to training documents from last year that were viewed by the Journal.

Kristen Bell, a nurse practitioner who left HouseCalls in May after doing home visits for seven years, said the prompts were one way to prod nurses to add diagnoses. They also got regular training about conditions they could record, she said. She characterized the message from management as: “I’m not going to beat you up about this, but I want you to go in this direction.”

Secondary hyperaldosteronism, a condition in which levels of the hormone aldosterone rise, is rarely diagnosed in traditional Medicare patients. HouseCalls documents show that its software would suggest the diagnosis if a patient had a history of heart failure or cirrhosis, and either took certain drugs, such as diuretics, or had swelling due to fluid retention. Nurses weren’t required to confirm the diagnosis with a lab test.

“In a million years, I wouldn’t have come up with a diagnosis of secondary hyperaldosteronism,” said Bell, the former HouseCalls nurse.

UnitedHealth diagnosed it 246,000 times after home visits, leading to $450 million in payments over the three years of the Journal’s analysis. All other Medicare insurers combined collected $42 million from making that diagnosis after home visits.

“It is a vastly underdiagnosed condition that is super valuable to call out,” said UnitedHealth’s Decker.

To find more cases of peripheral artery disease, both HouseCalls and Signify used the testing device that nurse Manke said she distrusted, company manuals show. 

The Food & Drug Administration said the device, called the QuantaFlo, “is not indicated for use as a stand-alone diagnostic device but as an adjunct to the diagnostic process.” Medical guidelines recommend against widespread screening for the condition.

A HouseCalls training manual advised nurses to diagnose peripheral artery disease based on results from the device. Managers at Signify told nurses they were required to use the device to test the patients of most insurers, a 2020 email shows.

Nurses diagnosed the condition after 568,000 home visits to UnitedHealth patients in the period analyzed by the Journal, adding up to nearly $1.4 billion in additional payments.

UnitedHealth’s Decker said the company expected clinicians to use their judgment in making peripheral artery disease diagnoses. A spokesman for Signify-owner CVS said medical providers decide when the test is appropriate on a case-by-case basis, and that the 2020 email was “not clearly worded” and didn’t reflect company policy.

Renae Cormier, chief financial officer of QuantaFlo maker Semler Scientific, said the device assesses risk for the disease.

Dr. Amy Chappell, a 73-year-old neurologist in Naples, Fla., was surprised when a nurse sent to her house earlier this year by UnitedHealth pulled out a QuantaFlo device. “She had no reason to think I had peripheral artery disease,” said Chappell, who says she has had no symptoms of the condition and is an avid runner and tennis player.

Chappell tested positive, although the nurse didn’t do any other standard exam to check for symptoms of the disease, Chappell said. Her primary-care doctor, Dr. Rebekah Bernard, said in an email that the diagnosis was inaccurate.

“From what I do know of the case, it’s an example of where we could have done better, and we need to own that,” said UnitedHealth’s Decker. The company later confirmed the diagnosis was a mistake and said it corrects such errors.

The Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress, has recommended that diagnoses from home visits shouldn’t count toward extra payments to Medicare insurers. The inspector general that oversees the Medicare agency has said it should reconsider the use of such diagnoses.

A spokeswoman for the Centers for Medicare and Medicaid Services, said the agency recently ramped up audits to verify diagnoses. The agency also is eliminating some diagnoses from those that qualify for extra payments, including peripheral artery disease.

Nathanael Lacaria, a nurse practitioner who did home visits in Colorado for CVS’s Signify unit in 2019 and 2020, said he didn’t feel it was appropriate to make definitive diagnoses based on one visit.

He said he didn’t realize insurers were submitting some of his tentative diagnoses to Medicare for billing purposes until a woman he had visited called the company to complain. “What’s this depression diagnosis in my chart?” she asked, according to Lacaria.

When he visited the woman, whose husband had died, Lacaria said, he recorded her answers to a standard depression screening tool, but he hadn’t actually diagnosed depression. “These visits were definitely used to jump to conclusions I wouldn’t have arrived at,” he said.

The CVS spokesman said Signify’s clinicians independently determine which conditions a patient has.

How The Journal Analyzed Medicare Data

The Journal identified insurer home visits based on an approach used by Medicare’s inspector general. The Journal excluded patients with more than two insurer home-visits or assessments by doctors in a calendar year. Insurers often add diagnoses based on audits that follow home visits, and the analysis included those, too.

The Journal determined diagnoses triggering extra payments were based only on home visits. Insurers sometimes add diagnoses without indicating a source, and when such diagnoses weren’t clearly linked to home visits, the Journal assumed they stemmed from other services.

The Journal calculated payments using an approach described in a previously published methodology. The analysis excluded certain beneficiaries, such as those who changed plans during a year and ones with end-stage kidney disease.

Graphics in this article are based on a Wall Street Journal analysis of Medicare Advantage and traditional Medicare claims data reviewed under a data use agreement with the Centers for Medicare and Medicaid Services.

At least 21 of Dr. Ricky Lockett’s Medicare patients died of overdoses, and he wrote 2,800 opioid prescriptions for those who survived them. ‘I try to be conservative,’ he said.

By Mark Maremont, Christopher Weaver, Tom McGinty and Anna Wilde Mathews
Photographs by Alyssa Schukar for WSJ

St. PETERSBURG, Fla.—Many who have died of overdoses in this retirement haven in recent years have a common thread. They were Medicare patients of Dr. Ricky Lockett, a local pain specialist.

Lockett is one of the nation’s most prolific prescribers of opioid painkillers to elderly or disabled people covered by the federal program, according to a Wall Street Journal analysis of Medicare data.

At least 21 of his Medicare patients died of drug overdoses between 2017 and 2021, the highest number for any doctor in the U.S., the analysis showed. Scores more survived overdoses. Some of them mixed prescription and street drugs.

Betty Jean Clark, a longtime Lockett patient on Medicare, died of an overdose at age 73. A week before Thanksgiving in 2019, police discovered Clark sitting motionless on a white sofa in her apartment in a senior-living community, wearing jeans and a plaid shirt. Nearby were pill bottles, including methadone prescribed by Lockett. There was evidence of cocaine use.

During the five-year period analyzed by the Journal, Lockett wrote more than 2,800 opioid prescriptions for patients who had previously overdosed, and prescribed the drugs at high doses to hundreds of patients a year, the Journal’s analysis showed.

The private companies that run Medicare’s prescription-drug plans paid for the opioids, even after the overdoses.

“I don’t like it for anyone to die, particularly on my watch,” Lockett said in an interview at his office here. “I try to be conservative. I know that I do.”

Lockett said hospitals rarely tell him when a patient survives an overdose, and patients themselves don’t always volunteer such information. That’s why he sometimes continues prescribing opioids to overdose survivors, he said.

Opioid abuse has mushroomed into a national crisis that thus far has defeated all efforts at a solution. In recent years, Medicare set out to limit the abuse of pain medications, but the controls it put in place proved porous and have failed to stop some doctors from prescribing dangerous amounts.

Medicare, which now covers about 67 million people, outsources drug benefits for many recipients to a network of private insurers under a program known as Medicare Part D. In 2018, it proposed asking those insurers to impose a daily dosage limit on opioid prescriptions in line with public health recommendations at the time.

But many pain doctors and insurers pushed back, arguing that an abrupt cutoff of high doses could be dangerous for long-term opioid patients and difficult to manage. Insurers didn’t want to have to mediate requests from doctors to make exceptions to the cap for certain patients.

The Medicare agency instead set the maximum daily dosage at more than twice the level it had initially proposed. The cap starting in 2019 was set at 200 morphine milligram equivalents—the amount of narcotic in 20 10-milligram Vicodin tablets, a very high dose for most people. Patients and their doctors could still seek exceptions.

And for the insurers, it was a recommendation rather than a requirement. Only half of Part D drug plans adopted it as of 2022, a spokesman for the Centers for Medicare and Medicaid Services said.

As a result, hundreds of thousands of patients continued to get potentially dangerous opioid dosages exceeding that higher cap, paid for by their Part D drug plans. The Journal analysis showed that 237,713 Medicare recipients got that dose or higher in 2021.

Researchers have found that the risk of overdose rises with dosage. A University of North Carolina study found that the overdose risk is at least 20 times higher at 200 morphine milligram equivalents a day than at 40.

While the total volume of opioids prescribed to Medicare patients has dropped, overdose deaths are more common than ever, the Journal found. 

About 13,500 Medicare recipients died from opioid overdoses in 2021, up 40% from 2017, the Journal found. Patients survived roughly 50,000 overdoses in 2021.

After they survive an overdose, many Medicare recipients continue to get painkillers, the Journal found.

More than half of 109,000 active opioid patients who overdosed from 2017 to 2021 were still getting opioids six months later through Medicare drug plans. Most of those were on even higher doses than at the time they overdosed, the data show.

Many of the overdoses are tied to illicit drugs such as black-market fentanyl, but prescription drugs paid for by Medicare insurers play a role. Around three-quarters of Medicare patients who were treated for overdoses had received pain-pill prescriptions at some point during the period analyzed by the Journal, many of them just before their overdoses.

“We still have a massive overprescribing problem, and there are few incentives for plans to care,” said Mark Atalla, a pharmacist and former Medicare official. Many plans will adopt opioid limits, he said, “only to the extent they are required to do it, because it is a cost.”

A Medicare spokesman said fighting the opioid epidemic is a priority. He said the agency’s rules aim to limit inappropriate prescribing while protecting patient access to needed care.

The Journal obtained the Medicare data, which doesn’t include patient names, under a research agreement with the federal government. The data includes information about doctor visits, hospital stays, prescriptions and other medical care patients receive. The Journal identified patients through police reports and medical-examiner records.

In analyzing opioid prescriptions, the Journal excluded drugs given to patients in hospice care or with conditions such as cancer and sickle-cell disease, who aren’t subject to the dosage cap.

Lockett said he knows he is an unusually heavy opioid prescriber. He attributed that to his population of patients, mostly on Medicare, who often come to him with longstanding pain and disability issues, and to his practice’s focus on medication-based pain management.

“I don’t give every individual as much as some docs do,” he said in the office where he sees patients, on the second floor of a 1970s-era medical-office building.

In 2021, Lockett prescribed opioids at or above the suggested Medicare cap to more patients than any other Medicare doctor in the country—409 of them, the Journal analysis found. They represented about two-thirds of his Medicare opioid patients.

He was one of 233 doctors and nurse practitioners who prescribed at or above that threshold to a majority of their Medicare opioid patients that year. 

Lockett said he moderated his prescribing after a 2022 advisory from the Centers for Disease Control and Prevention.

He said he regularly gives urine tests to patients to detect illicit drug use, refers those who fail to a psychologist, and sometimes requires “pill counts”—making patients come in midmonth to check whether they have the appropriate number of pills left.

Even with those precautions, he said, “once we have written the medication, we have no control of how they use it.”

Lockett said he wasn’t aware that Clark, his 73-year-old patient, had died of an overdose. He said he recalled her as a loner, but didn’t remember any problems. She just stopped coming, he said.

Rob Valuk, a University of Colorado professor of pharmacy, called the failure to notify doctors of overdoses a systemic problem. He said he’s worked with Colorado officials to develop a system to make such information more available to doctors.

Clark’s daughter, Yvette Gaugh, said her mother became addicted to painkillers after falling off a horse decades ago in Georgia. She later moved to St. Petersburg and began seeing Lockett, her daughter said.

“It was a slow downhill from there,” said Gaugh. Her mother, she said, “was acting all kinds of crazy.”

Clark’s Medicare records, provided by her daughter, show she was getting two painkillers—oxycodone and methadone—in the year before her death, along with a generic form of Xanax, an antianxiety drug that the FDA has warned since 2016 can cause respiratory problems or even death when combined with opioids.

Lockett said he wasn’t aware of public-health warnings about mixing the two types of drugs until 2022, after Clark died.

A spokesman for Humana, the Medicare insurer that covered Clark’s medications, said the company is “committed to help address the opioid epidemic.” He declined to comment on Clark’s case or Lockett’s prescribing, aside from saying that the doctor was no longer in its physician network.

Clark took to selling some of her drugs on the street for cash to buy other drugs, and at one point sold her BMW for drug money, her daughter said. Gaugh said she put her mother into rehabilitation programs three times, but nothing stuck.

She has kept a handwritten note her mother penned during one of her darker drug episodes: “If I make the nite I will change my life back.”

Around 2016, Gaugh said, she went with her mother to Lockett’s office to confront the doctor, but his staff wouldn’t let her in. “I wanted to tell him to stop prescribing my mom drugs,” she said. “I didn’t even know how he could prescribe based on the way she was acting.”

Lockett said he didn’t recall Gaugh asking to see him. If she was so worried, why didn’t she try harder, he asked, adding that he welcomes input from people concerned about his patients. “I need all the eyes on these people as I possibly can get,” he said.

An autopsy of Clark found opioids and cocaine in her blood.

“My mother was a normal person until she became addicted,” Gaugh said.

In 2022, Medicare tried to improve treatment for patients with a history of overdosing. It required insurers to monitor the opioid use of many of those patients and consider restricting their access, such as by requiring them to get all their pain pills from a single doctor or pharmacy.

Based on data for that year—for which full information was available for about half of Medicare beneficiaries—the rate at which patients who overdosed and went on to get drugs from multiple doctors or pharmacies declined only slightly.

Lockett, 66, graduated from the University of Pennsylvania and received a medical degree from the Philadelphia College of Osteopathy, according to Florida medical board records. He said he moved into pain management after watching rehab patients struggle to do exercises because of uncontrolled pain.

Lockett said the campaign against prescribing opioids has led some doctors to dial patients back to lower doses too quickly. “We know that a rapid decrease definitely will send them to some type of crisis,” he said.

Other medical experts also said shifting long-term opioid patients too quickly to safer treatments can cause withdrawal or push them to seek illegal narcotics.

“This is a really fraught clinical area,” said Dr. Marc LaRochelle, an addiction expert at Boston Medical Center. “What’s not clear is how to decrease the risk once people have been prescribed those medications.”

Until 2020, Lockett operated from a single-story building he owned in St. Petersburg. It faced a highway, across from a nonprofit serving homeless people.

Lockett said he moved to his current office because of the pandemic, citing air-quality issues at his old location. “No one felt safe there,” he said.

Court records show that months before the pandemic, a lender sued to foreclose on that building after Lockett failed to make payments on a loan, and he was later evicted.

Lockett said CVS Health pharmacies stopped filling his opioid prescriptions in November 2022, though he didn’t get a clear explanation. The move came as CVS was entering a roughly $5 billion settlement with state and local governments over its alleged mishandling of pain pills.

CVS’s Medicare drug plans kept covering Lockett’s prescriptions in December 2022, the data show—so long as patients filled them at other pharmacies, including at Walgreens stores. Later, Walgreens drugstores cut him off, too, Lockett said.

CVS declined to comment on any individual doctor. A spokesman said, “any single person overdosing on opioids is too many.”

Medicare drug insurers can block prescriptions from doctors suspected of fraud or other abuses, but otherwise generally are required to cover prescriptions filled at in-network pharmacies for drugs included in their coverage lists, said Xavier Baker, a healthcare lawyer at Groom Law Group.

In Dunedin, Fla., just north of St. Petersburg, sheriff’s officers in June 2021 found the body of a 36-year-old man, Kim Marston, slumped over in his apartment with four needles and an empty bottle of hydromorphone, an opioid painkiller. It was prescribed by Lockett 13 days earlier, and the container originally contained 84 pills, a sheriff’s report said.

An autopsy found fentanyl and Xanax in Marston’s blood, according to a report by the local medical examiner. That medical examiner recorded more than 20 deaths by overdose between 2018 and 2023 of people prescribed drugs by Lockett.

Marston’s mother, Rita Marston, said her son started taking opioids after being injured in a car accident years ago. He became addicted and stopped working, she said, and his personality seemed to change.

“I kind of blamed his doctor,” she said. When she went to his apartment to clean sometimes, she would find opioids and antianxiety medications prescribed by Lockett. “It seems like the doctor just kept doping him up,” she said. “It says take two a day. Christ, my son didn’t take two a day. More like four or six. It became like candy to him.”

Kim Marston’s death was “another one that hurt me,” Lockett said. He said Marston “never came in impaired whatsoever” and didn’t share that he had addiction issues.

Jeri King, a resident of nearby Tampa, said she contacted the Florida health department about Lockett after he kept prescribing opioids and other drugs to a friend even after the friend survived multiple overdoses. 

“Please, I am begging you,” she wrote the department late last year. “I’m profoundly concerned that her well-being along with others is in severe jeopardy!” King said in the email, which was reviewed by the Journal.

She said she also called Lockett’s office to warn about her friend overdosing.

Police records show her friend was twice taken to the hospital by paramedics in 2023 after suspected overdoses.

King, 54, a former insurance broker, said her friend kept getting drugs from Lockett. She showed the Journal photos of pill bottles with labels for two opioids—hydromorphone and morphine—prescribed to her friend by Lockett, filled this January and covered by her Medicare drug plan.

A few weeks after her friend received those pills, King said, she found the woman passed out, slumped halfway out of a car. Police records show officers responded to a suspected overdose and involuntarily committed the woman to a hospital.

Lockett said he wasn’t aware of any call from King to his office and wasn’t informed about any overdoses involving her friend.

In a text message to the Journal, the woman denied ever overdosing and asked not to be named. She said of Lockett: “He’s the only doctor I’ve ever met that cares about a person’s pain. Not just making a few bucks.”