Inflated Diagnoses for Profit
The way Medicare Advantage works is simple: the government pays private insurers a set rate to cover patients. However, when a patient is diagnosed with certain costly illnesses, the payment increases significantly. For example, an insurer gets $2,370 extra for a patient with morbid obesity or $2,180 for someone diagnosed with a stroke. This incentivized insurers to dig through patient records, add extra diagnoses, and submit inflated claims—many times without the patient ever receiving treatment for these illnesses.
According to the investigation, insurers were far more likely to diagnose Medicare Advantage patients with costly conditions like morbid obesity or diabetic cataracts compared to those on traditional Medicare. The data suggests this wasn’t coincidental—it was a strategic, profit-driven move to game the system. One particularly outrageous example is how over 66,000 patients were diagnosed with diabetic cataracts—despite having already undergone surgery to cure the condition. As Dr. Hogan Knox of the University of Alabama put it, “Once a lens is removed, the cataract never comes back. It’s anatomically impossible.”
