UnitedHealth says an external audit found nearly 97% of HouseCalls diagnoses backed by records

UnitedHealth Group said an external review of its HouseCalls in-home medical visits found that almost 97% of diagnoses identified through the program were supported by patients’ medical records or related paid claims. The company released the results as scrutiny continues around how Medicare Advantage plans use documentation from clinical encounters to support risk-adjusted reimbursements, an issue that has drawn both political and regulatory attention.

HouseCalls is UnitedHealth’s clinician-led program that provides older adults with in-home visits, with the stated goal of surfacing health issues and care gaps that may be missed in traditional office-based appointments. UnitedHealth said the audits concern diagnoses derived from HouseCalls visits that were submitted to the Centers for Medicare & Medicaid Services for Medicare Advantage payment purposes, a process that is central to how insurers are paid based on patients’ health profiles rather than just encounter counts.

According to the company’s disclosures reported by industry media, UnitedHealth engaged FTI Consulting to independently examine diagnosis coding accuracy. FTI randomly sampled 200 HouseCalls visits that were associated with 494 diagnoses. The review concluded that 97% of the diagnoses were supported by documentation in the medical record or by paid claims.

UnitedHealth also said the small share of diagnoses not supported by records and claims was 3.4%. The company characterized that unsupported rate as nearly three times lower than the error rate CMS reported in its most recent Medicare Advantage medical record audit, though it did not provide the underlying CMS audit details in the announcement coverage.

UnitedHealth framed the audit as a response to accusations that HouseCalls generated “trumped up” diagnoses to increase reimbursement. The company did not concede wrongdoing in the disclosures described in the coverage, but it said the independent review was intended to test diagnosis coding practices and reinforce the accuracy of the information used for Medicare Advantage risk adjustment.

In a statement reported by Home Health Care News, UnitedHealth Group CEO Steve Hemsley said HouseCalls visits make up a “small but meaningful” share of the more than 19 million home visits UnitedHealth clinicians make each year. The company also said the program includes follow-up care, including that a majority of participants schedule medical appointments within 90 days after a HouseCalls visit.

Still, several details were not fully spelled out in the coverage. UnitedHealth did not provide, at least in the reported announcement, the full methodology for how diagnoses were categorized, the exact time period for the visits reviewed, or whether the sample was intended to represent all clinical settings and provider types within HouseCalls. The results were described as initial findings from the external examination, with the scope and timing of any further work not clearly stated.

The near-universal diagnosis support rate is likely to be watched by policymakers and auditors given ongoing debate over Medicare Advantage payment accuracy. UnitedHealth’s next steps, including whether it releases more comprehensive findings and how it addresses any remaining error-rate risk, could influence how future scrutiny of risk adjustment documentation evolves for home-based care programs. For now, the company is betting that an independent, randomly sampled chart review will dampen concerns about coding intensity within HouseCalls.