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

[Winter2025VA]

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/

[GailL1]

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]

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-la...

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=searc...

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]

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.  

[LisaS961881]

Gail,

    I again have to agree that there is “no fox watching over the henhouse.”   That certainly helps explain the sheer volume and multifariousness of those Medicaid Fraud cases on the DOJ website.  You are right - it would take a massive army of auditors to wade through the morass of technicalities and ambiguities that are enabling these “bad actors” to readily commit fraud.  Maybe I am the most naive person on the planet, but seeing the results of my search on the DOJ website truly unsettled me.

 Again, like you mentioned, there needs to be “some stricter rules” - fine-tuning what may have been inadequate language, qualifiers, caveats - whatever was lacking in the original version of those rules.  

Thank you for that KFF Health News link.  I remember reading it and finally feeling validated.  

Because all of “this” is not in my wheelhouse, I truly prepared for when I turned 65 this past August.  I applied for Medicare on May 2nd and was approved the next day. 😄. I was so pleasantly surprised and relieved!

…..Then the “Healthy Home Visit” calls started -  over four dozen in all originating from eight different disguised or misnamed phone numbers! Even somebody like me wondered why the marketing of these visits was performed in a manner very similar to the aggressive “pump and dump” stock promotion calls that the actors made in the movie “Boiler Room”.  I wasn’t sensing an altruistic motive that’s for sure!

After receiving a cursory response from CMS that failed to address any of my detailed, written concerns, I was just so relieved when I read that KFF Health News Article.  I remember saying to myself, “ So I’m not crazy after all.”  Then I sat down and organized the data/notes, and phone call logs that I had accumulated from my experiences with the HHV subcontractor as well as my Medicare Advantage Plan Provider.  Then I filed a complaint with the DOJ on their website.  It might not have made any difference, but I felt much better just for trying! 😊

So glad that almost everyone is on board now, but I am still a bit worried that this is just the tip of the iceberg, 

• Thanks again!

 ~ Lisa 🌈🤞

[LisaS961881]

….Geez….I suppose that it’s odd that I’m replying to my own post, but I have an update of sorts that I’d like to share! 😊

    Again, for just a quick reminder of the sheer volume of Medicare Fraud that has been uncovered - here is a current link to the results you’ll find if you enter “Medicare Fraud” in the “Search News” section of the Department of Justice website:

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

While this still depresses and overwhelms me just as much as it did almost two months ago, today I read the article below and wondered why similar actions/penalties  have not been handed down more often as a deterrent to those contemplating committing Medicare Fraud:

https://ncpa.org/newsroom/qam/2025/08/21/cvs-pay-whopping-285-million-overcharging-medicare-and-lyin...

I would think a 285 million fine for bilking the system out of 95 million sets a great precedent.  Why isn’t this being done more often?  Or is this being done and just not being publicized as this judgement just was today?  I know that I smiled when I read this. 😇

Thanks just for reading this.

    ~Lisa 🙋☀️🐢

[Winter2025VA]

Lisa @LisaS961881 , I won't have the time to read your "very informative" (thanks for sharing). But I did want to say hopefully "moving forward" we will see more FRAUD being stopped. Way TOO MUCH going on for YEARS!!!  😤  Take care, Nicole!

➡️[*** LISA @LisaS961881 wrote:

….Geez….I suppose that it’s odd that I’m replying to my own post, but I have an update of sorts that I’d like to share! 😊

    Again, for just a quick reminder of the sheer volume of Medicare Fraud that has been uncovered - here is a current link to the results you’ll find if you enter “Medicare Fraud” in the “Search News” section of the Department of Justice website:

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

While this still depresses and overwhelms me just as much as it did almost two months ago, today I read the article below and wondered why similar actions/penalties  have not been handed down more often as a deterrent to those contemplating committing Medicare Fraud:

https://ncpa.org/newsroom/qam/2025/08/21/cvs-pay-whopping-285-million-overcharging-medicare-and-lyin...

I would think a 285 million fine for bilking the system out of 95 million sets a great precedent.  Why isn’t this being done more often?  Or is this being done and just not being publicized as this judgement just was today?  I know that I smiled when I read this. 😇

Thanks just for reading this.

    ~Lisa 🙋☀️🐢

---

[Winter2025VA]

@GailL1 , YOU SAID.

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

➡️[*** MY RESPONSE.

As one who is in the Medicare Extra Help Program, they CHECK all this. You have to supply your car info, bank info and so on.

*** They use your SOCIAL SECURITY NUMBER to get all up in your biz. Gone are the days when you could HIDE INFO. ***

[GailL1]

Not in every state - some states have it only based on self attestation of income and assets.  They don't check anything- well maybe a tax return if there is one - maybe. 

Then others have higher income limits - or they have removed any asset counting from the eligibility.  And some states may disregard certain income.   

It is all over the place what states determine their eligibility standards are for Medicaid in connection to the Medicare Savings Programs.

In fact, there are several states that have NO asset limit at all.  

* Alabama, Arizona, Connecticut, Delaware, Louisiana, Mississippi, New Mexico, New York, Oregon, Vermont, and the District of Columbia do not have asset limits for MSPs (as of January 2025).

KFF.org - Eligibility for Medicare Savings Programs for Specified Low-Income Medicare Beneficiaries ... 

Then there are other differences -

1. Alaska and Hawaii have higher income eligibility limits than the 48 contiguous states.

2. California eliminated the asset test on January 1, 2024.

3. DC only has a QMB program, with expanded eligibility to 300% FPL.

4. Maine eliminated SLMB and expanded eligibility for the QMB and QI programs in 2025.

5. New York subsumed its SLMB program into its QMB program in 2023.

Some of this will be changing soon - 

A question - if a person on Medicare has a home equity of over $ 750,000.00 should that be counted as an asset / resource for this welfare benefit?   

[Winter2025VA]

@GailL1 , from my understanding from folks who work in this career field, all they need is your Social Security Number to get ALL INFO. That is why we are told to "guard" our numbers. Never use to be this way.

As far as what assets and so on, people will be "selfish" & rather than SELL what they can, rather milk the system.

I can only speak for myself here in Virginia. GRATEFUL they "signed" me up for Extra Help as lol - I have zero to sell. Live in a Studio Apt & drive a 2006 Hyundai Elantra. Every month as soon as my only Income [Retirement Social Security direct deposit] hits my bank, the NEXT month's rent is paid online. No need to "forget" to pay = late fees/eviction. Anyway good insights Gail. Take care, Nicole!

[CBtoo]

There is a database that has all W2 information in it, all SS income in it, and other misc sources of income. Apparently it covers 94% of what people have coming in each year. It doesn't not cover assets they have unless there is income from it and you get a tax form (for example a 1099). SNAP uses that, HUD, uses that, some charities who money to individuals can access it... likely more that I can't think of right now or don't know about.

[GailL1]

---

@CBtoo wrote:

There is a database that has all W2 information in it, all SS income in it, and other misc sources of income. Apparently it covers 94% of what people have coming in each year. It doesn't not cover assets they have unless there is income from it and you get a tax form (for example a 1099). SNAP uses that, HUD, uses that, some charities who money to individuals can access it... likely more that I can't think of right now or don't know about.

---

Medicare Savings Programs, SNAP, and HUD use a combination of electronic data matching, direct third-party verification, and applicant-submitted documents to verify income and assets.  Federal law requires states to verify eligibility for these programs before approving or renewing benefits. 

But some states have removed all the assets from the test of eligibility for certain programs.(like California & New York) And some states use “attestation”  - as a method for verification. 

Certain assets don’t count - Exempt assets generally include an applicant’s primary home, household items and appliances, personal effects, a motor vehicle, burial plots, term life insurance, and in some cases, IRA / 401(k) retirement benefits.

Just depends on the benefit and who has the most charge over the program - state or feds. For the Medicare Savings Programs and SNAP - it is the state.  Although the feds can TRY to add more rules of eligibility. 

For HUD, that is a federal program only - although a state may also have a housing program.