Humana facing new federal scrutiny over private Medicare plans

By Fred Schulte, Center for Public Integrity 

The entrance to Humana headquarters in Louisville, Kentucky

The entrance to Humana headquarters in Louisville, Kentucky

Giant health insurer Humana, Inc. faces new scrutiny from the Justice Department over allegations it has overcharged the government by claiming some elderly patients enrolled in its popular Medicare plans are sicker than they actually are.

The Louisville, Kentucky-based company disclosed the Justice Department’s recent civil “information request” in an annual report filed with the Securities and Exchange Commission on Feb. 18. The company noted that it is cooperating with authorities.

“We continue to cooperate with and voluntarily respond to the information requests from the Department of Justice and the U.S. Attorney’s Office,” Humana wrote.

The privately run Medicare Advantage plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. By contrast, under Medicare Advantage, the health plans are paid a set fee monthly for each patient based on a complex formula known as a risk score. Essentially, the government pays higher rates for sicker patients and less for those in good health.

But overcharges related to inflated risk scores, intentional or not, have cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series published last year.

The Center first disclosed multiple investigations of the Humana Medicare Advantage plan last May based on records filed by the U.S. Attorney’s Office in a Miami civil suit.

But Humana’s SEC disclosure offers fresh details into the wide scope of the Justice review, indicating it is taking aim at a range of common Medicare Advantage billing practices and fraud controls, as well as Humana’s use of home health assessments of patients in its plans. The industry argues these “house calls” improve the health of elderly patients, but federal officials have been concerned that the primary objective is to raise risk scores and revenues.

Humana said the Justice Department had requested a range of records about “our business and compliance practices related to risk adjustment data generated by our providers and by us, including medical record reviews conducted as part of our data and payment accuracy compliance efforts, the use of health and well-being assessments, and our fraud detection efforts.”

The government probe comes at an inopportune time for the burgeoning Medicare Advantage industry, which is mounting an intense lobbying and advocacy effort to stave off proposed government funding cuts.


The Centers for Medicare and Medicaid Services is set to release proposed funding levels for 2016 on Friday. More than 16 million seniors have joined these private health plans. Humana has enrolled about 3.2 million people in Medicare Advantage plans.

What will happen to the rates is not yet clear. But the Obama administration’s 2016 budget seeks to cut some $36 billion from Medicare Advantage plans over the next decade related to oversized risk scores.

Allegations that some Medicare Advantage plans manipulate risk scores, a process known in the industry as “upcoding,” have been surfacing over the past year in the federal courts.

The Center for Public Integrity has previously reported on several of these whistleblower lawsuits, including one filed by a Miami doctor against Humana.

In that case, Olivia Graves alleges that a Humana medical center had diagnosed abnormally high numbers of patients with diseases such as diabetes with complications that boosted Medicare payments — diagnoses that “were not supported by medical records.” Graves alleges that Humana knew about the overcharges but took no action to stop them. Humana has denied the allegations.

And in early February, a federal grand jury in West Palm Beach, Fl. indicted Dr. Isaac Kojo Anakwah Thompson on eight counts of health care fraud. He’s accused of cheating Medicare out of about $2.1 million by inflating risk scores of some Humana-enrolled patients. Thompson, 55, is free on a $1 million bond and has declined comment through his lawyer.

The Florida indictment did not accuse Humana of wrongdoing, but company spokesman Tom Noland said that it had repaid the government. He declined to say how much.

New scrutiny of home visits also could prove troublesome for the industry. At least one whistleblower, a former manager at a California firm that does medical home visits, has alleged that the process was abused to inflate risk scores.

Humana has been a major promoter of these home assessments. In an email to the Center today, Noland wrote: “We believe in continuing to do in-home assessments as we see this as an important step in establishing care management plans for our members living with multiple chronic conditions.”

Noland declined to say how many of the home assessments Humana has performed. But the company has previously said that it conducted the assessments for about 531,000 members in the first three months of 2014.

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  • I felt my family member’s overall health and quality of life
    improved since she had no reoccurring hospital stays or ER visits in two years, however Humana insisted on visiting to do a “change of condition”. I requested that the visit be postponed a few days pending a callback from who I did not disclose to them but I was waiting from a return call from Humana’s own board of director’s representative. My request to postpone the visit and to whether there was a deadline to complete their visit to do a “change in condition” or to do a 90 day home visit, which there were about 10 days left to meet the 90 day end date resulted in Humana ending the conversation abruptly and within a few days Humana Long Term Care’s Miami offuce, and the provider from Miami Beach Community Health Center and the home health agency got together and filed a Elderly Neglect complaint with Department of Children and Families with bits and pieces of unsubstiated undated notes and unavailableable missed appointment dates and several other details that could have been fact checked and found to not be accurate. Humana’s Long Term Care’s Scarlett Tejedra complained that I was unfit as a caregiver saying I didnt follow medical advice. Based on Humana’s complaint they removed my family member from our residence, claimed it was to do a wellness check, then later wrote she had been Baker Acted by Police because DCF investigators LaPetite, and Sonya Hernandez feared for her safety in our residence, but the member had refused to go with them, and they took her anyway. There is no record of a Baker Act. She was hospitalized with low blood sugar (due to interruption in our meal schedule while DCF did their investigation). Instead of being stabilized and sent home, o the very next day DCF was looking for a nursing home to place her in. On Oct 14th 2019 DCF said the hospital sent my relative for rehab, but on the 17th a petition was filed and on the 22nd the judge placed my family member into adult protective custody. The court attorney informed me DCF listed me as a witness not the caregiver and did not have to notify me about any future court hearings even though Humana complained that I was unfit to be the caregiver. Humana’s complaint and DCF misled the judge. The judge moved up the hearing time on the 22nd signed all the protective custody documents without hearing from me l. Then in a make up Hearing on the 29th the judge accused me of being late for first hearing and missing it, and was speechless when I told her her staff had told me that she had changed the hearing time. The judge hadn’t checked any records of facts, and refused my cell phone videos of my relative speaking verbally, requesting to go home, and other email evidence. At that point I think the judge had to go along with DCF and Humana because she had already signed the protective papers without hearing from me on the 22nd. Consequently my relative who was removed from her brand new assisted living apartment on Oct. 10, 2019 and put in a nursing home that practiced solitary confinement and sleep deprivation and gave no blankets to her unless requested, often was barely clothed in dining room while others are fully clothed and ate by mouth and my relative was put in a continuous feeding tube but watched others eating by mouth and checked by DCF only twice by in 19 days while I was still allowed to visit at that time I was advised by one judges office to call the police if I was concerned about my relative safety I called the police three times who wrote reports that left out details, the Agency for HC Administratiion who found no problem in nursing home, the FBI who didn’t issue a case or call number and may or may not investigate, commissioners referred me back to courts and declined to protect my relative, a mayor assistant who said I’ll tell him. This is just a short list I sought out assistance and got little or no help and then got barred from nursing home, by DCF. In a few days February 12, 2020. The State will probably take over my relatives life completely and she will lose her beautiful new residence for the disabled, and they will probably charge me with whatever they can. All because I began asking Humana Long Term Care in Miami why they over a period of two years delayed, suspended, or terminated services and equipment we needed to improve my relatives condition. I struggled to improve her condition and had successfully stopped the revolving door of ER and hospitalizations, we both lost 4 sizes in clothes with her diabetic nutritionist meal plan, hers with blended and soft foods. Humana said since she had not seen a gastro doctor for her peg tube that I should not have fed her by mouth even though most gastro providers at University of Miami has a 60 to 90 day waiting list for appointment availability and private Gastos did not take Medicaid.Jowever Humana attributed the blame for bad weather events, coordinator errors, provider cancellations, all to my to reschedule appointments and blamed me across the board with accusations but presented nothing in court but verbal accusations, with no dates, times, few names, nothing from medical records, no policies or procedues. However I had to reconstruct all the events and dates listed in the complaint and confirmed the facts was amazed how these shallow misleading statements had been successful in initiating this process and taking custody of my relative even though I had kept records and calendar notes and letters for several years. Since then Ive learned that Medicaid pays Humana 35 percent of any invoice Humana proves they saved them money on even if service or equipment was delayed, denied , Pended, and then terminated. Also add in what Humana and providers got paid for case management, whether the member got their services or saw their providerbor not. Primary care physicians only saw patients if patients called for an appointment. I learned that members got sicker and their bones and tendons constricted without concurrent therapy and caused pain, and this led to a need for pain meds and the patient becomes sedentary, breathing issues, UTIS, Falls and even obese and depressed and withdrawn without speech therapy and day activity approvals. And that could all morph into other problems that could have led to reoccurring hospitalizations. In Wikipedia it’s called “ethical lapses” which Humana has been criticized for their lapses in services and limitations. To it’s members. (See Wikipedia Humana). Ironically they succeeded, one way or the other, they have my relative in custody, they wanted the member revaluated for a change in condition which is most likely also a risk assessment mentioned in this article which would have gotten them more money, which I don’t think my relative met their high risk criteria any longer since she had not been hospitalized in two years and had not required oxygen except during last hospitalization in May 2018, and her Diabetic doctor was moving her to low dose pills and away from injections, and many doctors said soft foods by mouth were permitted, and that a peg tube should only be a only temporary resource. So since Humana couldn’t get more money they settled for taking over the members entire life and passed it over to sustain other healthcare professionals. I had already changed the members health plan but would have gone into effect December 2019. Today as my relative waits in the nursing home for her future life to be decided, this above average woman who I could talk to about many things who I marvelled at her wisdom about family life and even her own ability to know when she needed additional help with complex decisions, to have to accept that she will most likely be declared o be incompetent or incompacitated from what could more likely due to depression, and the loss of her Mother in 2017, and being taken from her residence and neglected and abused in their nursing home care early on. Please also note that I was a paid caregiver @$10.25 an hour for 40 hours a week but a live in caregiver. I received the invoice from Humana it cost between $10 and $12,000 monthly for her to be in this rehab facility and she told me in a phone conversation she is not receiving rehab and I know she is not getting new dentures, or seeing her cardiologist, or even a gastro specialist because all of these appointments had been scheduled before she was taken but for the months she’s been in the rehab facility.
    And last but not least I found that lawyers do no want these cases perhaps because DCF is involved. They won’t really say why. Ive spoken to about 10 lawyers so far who asked me many details but all turned down the case. I’m currently looking for help with guardianship firms to submit to the courts. I can be reached at [email protected].

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