Medicare Advantage: When insurance companies make house calls

Beverly Merz
Beverly Merz, Executive Editor, Harvard Women's Health Watch

When I was growing up, my doctor still made house calls when we were too sick to get to his office. But he stopped visiting people at home long before he retired. Both he and his patients realized they were perhaps better served by going to his clean, well-equipped office for whatever care they needed.

So I was more than a little surprised when a woman representing my health insurance plan called to schedule me for a home visit from either a nurse practitioner or physician. I have a Medicare Advantage plan, and I thought I was being offered this visit because the caller assumed I was frail and house-bound. I assured her I could easily get to my doctor’s office if I needed to. I’d also just had my annual physical, my immunizations and screenings were up to date, and I felt great. Why would I need a home visit?

The only reason she could give was that the clinician would have more time to spend with me than my own doctor did. The home visit would last 45 minutes to an hour and would include a health history, a physical exam, screenings, and health advice. Since I work full-time, I could schedule the visit for a weekend. And she’d even throw in a $25 Walmart gift card if I completed the exam.

I declined, feeling a little creeped out — especially after checking with my doctor and learning that she knew nothing about this. So I did a little research.

I learned that these visits are legitimate — in fact, over a million patients have signed up for them so far. And I learned that the extra exam had reduced hospitalizations, primarily for patients with diabetes, heart failure, or chronic obstructive pulmonary disease. But what still puzzled me was why my insurer would want to incur the extra expense of duplicating the exam and tests I had just gotten from my doctor. I don’t have any serious conditions and my doctor consistently receives top grades from all the ratings systems.

A method to the supposed madness

Dr. Michael McWilliams suggested an answer. As an associate professor of health policy at Harvard Medical School, he understands the arcane regulations that cover how Medicare reimburses my Medicare Advantage plan for the care I get. He told me that each of us covered by these plans is assigned a risk score. As we develop more health problems, our risk score increases. “The home visits conducted by Medicare Advantage plans allow for the capture of more diagnoses, which in turn increases the risk score that adjusts plan payments from Medicare.  Generally speaking, the more diagnoses recorded, the higher the payment,” Dr. Williams says.

He explains that the risk adjustment system was created to ensure that plans don’t enroll only the healthiest patients, who are less likely to run up charges for expensive procedures and hospital stays. To provide an incentive for insurers to cover sicker patients, the plans are paid commensurately more for their care.

I’ve received two more calls since I first declined the home visit, each more persistent than the last. Now I understand why. If the clinician could diagnose me with a serious health condition, the company could raise my risk score and get a higher Medicare reimbursement each time I visit the doctor.

What to consider if you’re offered a home visit

If you or someone you know is offered a home visit from a Medicare Advantage plan, keep the following in mind:

  • If you have a serious health condition, the extra care might help you avoid a hospital stay.
  • The care they provide isn’t ongoing. This is the only time you will see the clinician who examines you. The results of the exam and tests will be forwarded to your regular clinician for follow-up.
  • If you are healthy and the visit results in an increased risk score, you won’t have to pay more for your care. But the higher Medicare reimbursement your insurer receives may contribute to the nation’s rising health care costs.
  • You are not obligated to have a home visit — they’re completely optional.

Related Information: A Plan for Successful Aging


  1. Dianne

    Exactly right!! It is very disconcerting that we pay for Physician care and expertise, but in the end, the insurance company decides what is best for us.

  2. Lynn

    If an insurance company wants me to waste an hour of my life to help them make greater profits, they’re going to have to offer me more than a $25 Walmart gift card! I’m thinking an hourly rate of, ooh say $1000 might be more reasonable. What is it worth to them? The higher HRA score must give them a big financial bump, since they are spending the money to hire an NP or physician to drive around and do house calls on weekends! As for the Walmart gift card, I’d love to know if Walmart gives these to the insurance companies for free (as a loss leader to get people in), or if they are given at a discount rate or with some other kickback arrangement between Walmart and the insurance companies?
    In the end though, what a waste of time and money, duplicating services, confusing the patients and their physicians, and possibly causing harm by making extra unnecessary diagnoses, leading people to think they are sicker than they are, creating psychological distress and creating more people who are the “worried well.” First do no harm – that is more important than increasing insurance company profit.

  3. Maribeth Miles

    Big Pharm/Big Insurers are making mucho dinero courtesy of Obama and his fraud-based scheme. Shame on our legislators but special shame o Mr. Obama who had the opportunity to implement Medicare for all/single payer and instead perpetrated this!

    • Kirsti

      Seriously! Are you telling me that he could have pulled off single payer? He almost came up totally empty. He got something, despite the odds. Republicans must have discovered that the sky didn’t fall. Life continues after Obamacare. Next step : cut out the middleman, insurance industry.

  4. Peter Brewster

    Dan’s comment sounds to me like justifying a search for positives by way of unsolicited income-yielding exams. You’re bound to find some positives – especially if you’re not looking for negatives. Dan’s MA reflects too much bean-counter influence and too little thought-out health care interest.

  5. Dan

    This is a very nice summary of the Health Risk Assessment (HRA). For full disclosure, I do work for a Medicare Advantage (MA) plan. I just wanted to clarify one aspect of your “what to consider” summation. You state, “If you are healthy and the visit results in an increased risk score, you won’t have to pay more for your care. But the higher Medicare reimbursement your insurer receives may contribute to the nation’s rising health care costs.” This is not a completely accurate statement. True, the MA enrollee will not pay more in premium and cost-shares in the current plan year, but based on the plan’s financial performance, unidentified conditions will lead to lower reimbursement to the plan from CMS than they are otherwise entitled to, which leads to higher Medical Expense Ratios (cost paid-out in claims for every dollar in revenue). As the MER increases, along with increasing medical trends, the plan is forced to increase premium and/or member cost share, or remove additional coverage like comprehensive dental or vision benefits not covered by Medicare in subsequent years. Identified or not, the condition will eventually impact the national cost of care. So, I propose your statement is incomplete and misleading. For every unidentified risk factor, over time, the members cost will go up and will still contribute to “the nation’s rising health care costs” regardless. There really is no down side, other than perhaps 45-60 minutes of your time, to receiving an in home Health Risk Assessment (of which in many cases the plan rewards you for as you indicated in the gift card offer). Also note, the HRA doesn’t have to be completed in the home. It is actually more economical for the plan if the HRA is completed in the Primary Care Physician’s office (the physician is often compensated for the extra time it takes). This is something your provider should be doing anyway. I do not know what insurance carrier your MA plan is with, but when they called you, they should have given you the option to have an in home assessment or schedule an assessment at your doctor’s office. This should be completed every year. In fact, conditions identified in one year do not carry over to the next. For example, an amputee identified as such in one year will increase the risk score. However, unless the HRA identifies the missing limb in subsequent years, CMS assumes the limb miraculously grew back and the score will adjust down. MA plans are not trying to scam the system. They are simply trying to identify all conditions to maximize the Risk Score so that CMS pays the appropriate amount for each Medicare enrollee’s care, no more, no less. This also allows the plan to identify and encourage better care management plans that can lead to better quality of care and quality of life as well as help prevent more costly treatments and care like hospital stays etc., which will in turn help minimize “the nation’s rising health care costs.”

    • Lynn

      The insurance company also should have been honest, open, and forthright about WHAT they were doing, and WHY, including their financial interest and potential benefit. Starting out of the gate with omission of these facts is shady and deceptive.

    • Lynn

      It is also not the insurance companies’ job to “identify and encourage better care management plans.” What a load of hooey – that is the primary physician’s job, not an insurance company’s job! Insurance companies flood physician fax machines with useless “helpful suggestions” that are ridiculous and waste time and mental energy – not to mention ink and paper – I’ve seen it! If insurance companies stopped playing physician, and stopped creating extra busy work for physicisns, then physicians could have more time to do their own jobs! It’s backwards now, with insurance companies trying to practice medicine, and physicians being forced to play at being paper pushers!