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SummerOnTheWay1
SummerOnTheWay1
July 17, 2025

📋 AARP Endorses Bill to Stop Medicare Advantage Upcoding (AARP Article,Advocacy)

  • July 17, 2025
  • 10 replies
  • 6548 views

FROM THE ARTICLE.

 

AARP Endorses Senate Legislation to Stop Medicare Advantage Plans’ Excess Billing.

Bill would curb plans’ ability to inflate patient diagnoses, increase government payments.

 

By Tony Pugh, AARP.

 

*** There are 3 comments on the AARP website. Stop by to add yours. **?

 

Published July 16, 2025.

 

AARP is backing bipartisan congressional legislation designed to stop Medicare managed-care plans from inflating patient diagnoses to boost their payments from the federal government.

This practice from privately run Medicare Advantage plans, called “upcoding,” is expected to increase the cost of care for Medicare Advantage plan enrollees by $40 billion this year, compared with the cost to cover similar patients in original Medicare, according to the Medicare Payment Advisory Commission.

 

USE LINK BELOW TO READ THE ARTICLE.

 

https://www.aarp.org/advocacy/medicare-advantage-excess-billing/

10 replies

GailL1
July 17, 2025

I think most everybody is onboard with this and they even have agreement from some of the largest insurers agreeing to this too.  Beats being in court all the time.  One does have to wonder where previous Administration’s Center for Medicare and Medicaid Services (CMS) thoughts were on this thru the years.  Seems some stricter rules for Medicare Advantage insurers would have fixed the problem way before now -  

LisaS961881
LisaS961881
Community Champion ⭐⭐⭐
July 17, 2025

Gail, I am most certainly not an expert in any of this, but months ago, what I could locate about the DOJ’s 2021 investigation, seemed to be describing how the DOJ made a request that the CMS specifically monitor multiple Advantage Plans due to a statistical anomaly that the DOJ discovered.   It appears to me that CMS’ reply was, “Yea, but it’s legal - we got this - leave us alone.”  

    Page 4 - second full paragraph:

 

https://www.wilmerhale.com/-/media/files/shared_content/editorial/publications/documents/20240112-law360--lessons-from-dojs-handling-of-rare-medicare-fraud-case.pdf

Apologies -  every other link I have has a paywall, and I can’t find the links on MSN.  

But I do believe you are spot on - now that the dirty laundry is flapping in the breeze, it most certainly “beats being in court all of the time”.

 

And again, maybe take a second look at how abundant Medicare Fraud is - this is a link from the DOJ Website when I searched “Medicare Fraud” in the “News” section of the site.  I started adding up the totals last week and became so disheartened that I stopped doing so.  All those grifters bilked the system for millions!  

 

Here’s my link and, of course, no firewall:  😄

 

https://www.justice.gov/news?search_api_fulltext=+Medicare+Fraud&start_date=&end_date=&sort_by=search_api_relevance

 

it’s just such a colossal waste, and I truly believe you are right - maybe just a few “stricter rules” could have made a difference.  At least some movement appears to be happening now.

 

~ Lisa 🌈 

 

    GailL1
    July 17, 2025

    Here is a rather complete synopsis of the problem - currently and historically.

    KFF Health News - 11/08/2024 - Watchdog Calls for Tighter Scrutiny of Medicare Advantage Home Visits 

     

    CMS controls Medicare and Medicaid (federal level) and with that - they control the insurers - they do this control by rule making.  However, then they never go back to see how the systems set up to work within these rules actually work.  

     

    Where government programs are concerned, there is a lot of waste, fraud and abuse purely because there is no fox watching over the hen house.  That would take an army of auditors. 

     

    And I am not talking about these Medicare Advantage plans over stating the diagnosis of some of their covered beneficiaries.  Like you, I look at the DME provider system that even now have a massive amount of fraud.  

     

    To me, it is the pure size of the Medicare/Medicaid programs that has a lot of fault.  We try to fit everybody into some specifically designed nitch for specific populations, develop a plan for each of them and then  the beneficiaries get lost in all the complexities.

     

    Do you think there is also waste, fraud and abuse in some of the Medicare Advantage plans that are using the ‘giveback” program?  

     

    Wonder how many beneficiaries are on one of the Medicare Savings Programs erroneously because they are understating their income or asset / resource limit.  

     

     

     

     

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