Medicare Advantage (MA) plans, also known as Part C, are private health plans that provide Medicare-covered benefits. Over the years, concerns have grown about how insurer-initiated home health assessments have been used to capture additional diagnoses, sometimes leading to higher reimbursements from Medicare.
In 2025, major insurers, including Humana and UnitedHealth, will have publicly endorsed efforts to limit how diagnoses from these home visits are used in the billing process. The reforms are aimed at:
These changes are consistent with broader efforts by the Centers for Medicare & Medicaid Services (CMS) to curb fraud, waste, and abuse in the healthcare system.
Humana is one of the largest health insurance companies in the United States, best known for its strong presence in the Medicare Advantage (MA) market.
In addition to MA plans, Humana also offers Medicaid coverage, employer-sponsored health plans, and specialty benefits like dental and vision. Its focus on serving seniors has made it a key player in shaping policy and reimbursement practices within Medicare Advantage.
UnitedHealth Group, the largest health insurer in the U.S. and one of the biggest healthcare companies globally, operates primarily through two divisions: UnitedHealthcare, which provides health insurance coverage including Medicare Advantage, Medicaid, employer, and individual plans, and Optum, which offers healthcare services, data analytics, pharmacy benefit management, and technology solutions. Like Humana, UnitedHealth has a dominant role in the Medicare Advantage space.
Together, Humana and UnitedHealth cover millions of Medicare beneficiaries, and their endorsement of billing reforms such as limiting the use of insurer-initiated home visits in risk adjustment signals a major industry shift. Their support not only influences how other insurers respond but also has direct implications for healthcare providers and billing processes across the U.S.
Why These Billing Reforms Matter
The Role of Billing in Medicare Advantage
Accurate and HIPAA-compliant billing solutions are the foundation of fair and transparent reimbursements under Medicare Advantage (MA). Because Medicare Advantage plans are funded by the federal government but managed by private insurers, every diagnosis code and billing entry directly affects how much CMS pays insurers, and in turn, how providers are reimbursed.
When billing processes rely on questionable diagnoses such as those captured only during brief, insurer-initiated home health assessments, it can create distortions in the risk adjustment system. This is why recent reforms, supported by Humana and UnitedHealth, are aimed at ensuring that risk scores are based on ongoing, clinically documented care, not isolated encounters.
The consequences of inaccurate billing or poor documentation can be serious:
For healthcare organizations, the reforms highlight a simple truth: Billing is not just about getting paid; it is about maintaining integrity, compliance, and trust in the Medicare Advantage system. Providers must now double down on:
By strengthening these areas, providers can ensure their claims withstand audits, avoid costly penalties, and keep their billing processes aligned with both insurer policies and federal regulations.
10 Frequently Asked Questions (FAQs)
Medicare Advantage (Part C) is an alternative to traditional Medicare, offered by private insurers, covering hospital, medical, and often prescription drug services.
CMS is tightening rules on how diagnoses captured during insurer-initiated home visits can be used for risk adjustment, reducing inflated reimbursements.
Both insurers have endorsed reforms to increase transparency, reduce regulatory risk, and strengthen the credibility of the Medicare Advantage program.
Providers must ensure that diagnoses used for reimbursement are documented during ongoing patient care, not just one-time assessments, requiring accurate billing and coding.
The Centers for Medicare & Medicaid Services sets the rules for Medicare Advantage reimbursement and enforces compliance across insurers and providers.
The goal is not to reduce care but to ensure that risk scores and, therefore, payments are tied to ongoing, medically necessary services rather than isolated assessments.
Outsourcing to certified billing specialists ensures claims are coded accurately, HIPAA-compliant, and aligned with current Medicare Advantage regulations, reducing audit risks.
CMS has already begun phasing in stricter guidelines, with further refinements expected through 2025 and beyond. Providers should stay informed and adjust billing processes accordingly.
Claims may be denied, adjusted, or flagged for audit, and in some cases, providers could face financial penalties.
Providers should partner with medical billing services that specialize in Medicare Advantage, conduct regular compliance audits, and ensure all diagnoses are fully supported in patient records.
How Bridge Billing Services Can Help
Navigating Medicare Advantage billing reforms requires expertise, precision, and compliance-driven processes. That’s where Bridge Billing Services comes in.
We provide:
By outsourcing your billing to Bridge Billing Services, your practice can focus on patient care, knowing your revenue cycle is protected.
📞 Contact us today to learn how we can streamline your billing processes and help you stay compliant with Medicare Advantage reforms.
The support of Humana and UnitedHealth for Medicare Advantage billing reforms reflects a growing consensus: billing must prioritize accuracy, compliance, and patient-centered care. For providers, these reforms mean adapting workflows, improving documentation, and embracing trusted billing partnerships.
With a reliable partner like Bridge Billing Services, you can remain financially strong, compliant, and focused on what matters most: delivering exceptional patient care.