What Ideas Do You Have To Hold Down Medicare Part B Premiums?

[GailL1]

IF you are not one of the millions that currently has their Part B premiums paid by your state’s Medicaid program, then you will see an increase in these premiums for 2026.  Estimates that I have seen, but yet have been announced, shows that we could top over $200 a month for this cost in 2026 for just regular Part B premiums.  Then, of course, those with higher income will be paying a whole lot more for their Part B premiums in the form of IRMAA payments (Income Related Monthly Adjusted Amount).

So do you have any suggestions on how to hold down these Part B cost?  In that regard, you have to know what Medicare Part B covers, how waste, fraud and abuse affects the program financially and the coverage determinations that affect it in usage.  

Like this one:

It has long been the process of moving procedures that were at once considered major operation (Medicare Part A) to being done on an outpatient (ambulatory) status (Medicare Part B).  To me, that isn’t saving money - that is just moving around the part of Medicare paying for this service.  It takes the coverage strain off of Part A (paid for via your payroll taxes and matched by your employer) and puts it on Medicare Part B that is paid for by all Medicare beneficiaries whether directly or indirectly.  It also ups the cost of Part B.  

[Tonster521]

@gail1, I believe most folks would opt for a larger Part B deductible if the Part B premium/contribution is decreased appropriately. Maybe add a $500, $1,000, or more deductible option that can be changed from year to year during October and/or November. In my opinion, the current 25% ($185) is an outstanding deal when compared to the estimated full cost ($740). I would also recommend that folks below a certain income level do not have any premium/contribution. To require those folks to pay/contribute the same as the wealthy is a shame. Congress just gave over $200 Billion of SS Benefits to folks with a "gold plated" government pension by eliminating the Government Pension Offset and Windfall Elimination Program. Many of those folks have government pensions that have present values in the hundreds of thousands if not millions. In Illinois, the median (not average) pension in the Teacher Retirement System is approximately $65,000/year. In cash payments, that will amount to $1,950,000 for an age 55 to 85 retirement. Moreover, many start full pensions in their 50's as opposed to the SS program which the earliest is age 62 and actuarially reduced. For comparison purposes, I believe the median SS Benefit is somewhere around $25,000 to $27,500/year. For these folks, Medicare should be provided with no additional premium/contribution. Same concept as the ACA (Obamacare). Additionally, there is no logical reason for providing a 75% Part B subsidy for higher income folks. The IRMAA income schedule should be adjusted to more reasonable income levels starting much lower than the current schedule. In simple terms, if one has more income, the subsidy is less. Medicare, just like all insurance benefits, are welfare benefits. Why does the Medicare program especially Part B subsidize highly compensated folks at the expense of the non-highly compensated folks?

[GailL1]

@Tonster521 wrote

I believe most folks would opt for a larger Part B deductible if the Part B premium/contribution is decreased appropriately. Maybe add a $500, $1,000, or more deductible option that can be changed from year to year during October and/or November

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That could work for many beneficiaries, suites me  - except those with those very lucrative Medigap plans - cause then they would have to pay them since NO Medigap plans now can cover the Part B deductible.  

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@Tonster521 wrote 

I would also recommend that folks below a certain income level do not have any premium/contribution.

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That’s already done via the Medicare Savings Programs - state Medicaid pays their Premiums and even other stuff depending on the program they are in as they are described.  Some will also get full Medicaid coverage while others will only get the described things covered.  Part B deductible is constant in each of the programs.

Medicare.gov - Medicare Savings Programs  (Federal Levels) 

One thing that does bother me with the Medicare Savings programs - the eligibility income and asset levels are shown for the Federal level however states can make these more lenient and many do - in fact many states have NO asset level at all.  And then some states have a much higher income eligibility - 

I do not think that his is a MEDICAID program that is matched by the Feds as most are - BUT I DO NOT KNOW FOR SURE.

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@Tonster521 wrote

To require those folks to pay/contribute the same as the wealthy is a shame

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The wealthy pay a lots more - The IRMAA is a Part B adjusted premium that those with higher incomes pay into the Medicare Part B program to cover more than 25% of the beneficiary cost.

SSA.gov - Premiums: Rules for Higher-Income Beneficiaries 

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Please do not get me started on the Social Security “Fairness” Act - we do agree that it was plain stupid the way it was done - especially when there was a new formula that could have been initiated instead of the way it was done.

A friend of mine got a $ 30,000 check and now in addition to her $ 75,000 civil pension she is getting a $ 3,000 Social Security retirement check every month.  Course she is now having to pay the monthly IRMAA premiums every month and she is griping about that - LOL.  Even she think she got a windfall since she never paid one cent into Social Security her whole working life.  

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@Tonster521 wrote 

Additionally, there is no logical reason for providing a 75% Part B subsidy for higher income folks. The IRMAA income schedule should be adjusted to more reasonable income levels starting much lower than the current schedule. In simple terms, if one has more income, the subsidy is less.

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That is specifically how the IRMAA works (see the SSA.gov link about for the explanation).  But yes, I would agree that the income limits here should be removed from the inflationary requirement - leave them standing at the current level or lower them - I opt for leaving them at current level and then more and more people will get included in it as time goes by.  Just like the Taxes on benefits was designed to work.

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I don’t think our Congress has too much on the ball when it comes to math, actuaries, etc,  Our huge deficit should reaffirm this - they cannot add or subtract.  Thank goodness we do have some that can do it but they don’t seem to be in Congress rather they are supportive staff.  And the numbers don’t seem to matter when Congress decides to GIVE something.  

[Tonster521]

@gail1, Generally, people want free or no cost items including insurance benefits. As many of us know, nothing is free. Someone or some institution may be paying for those items or costs on one's behalf including taxpayers. Many are not concerned with shifting costs as long as they did not have to pay. Some will pay a high premium for Medigap coverage with the expectation that both Medicare and Medigap coverage will pay all hospital/medical expenses. So, accepting a higher deductible in exchange for a lower premium may not be a priority. Even though accepting a lower premium may be a sound financial decision, I agree some will not elect a higher deductible because they will have to incur and pay some hospital/medical expenses. 

With regard to the Medicare Savings Program, many eligible folks either do not apply for help or are frustrated with the application process. It is estimated that less than 60%  of those eligible apply for help. I will try to copy and paste a link to an article from Medicare Rights Center https://www.medicarerights.org/policy-documents/medicare-savings-programs-a-lifeline-for-millions One would think that a Medicare Saving Programs should be administered without unnecessary "red tape", bureaucracy, and a reasonable income threshold. That is why I suggested a benchmark income level and eligibility is approved. Assets are another issue that needs to be determined. I am not sure if States contribute any money to the MSP. However, the Fed simply waives the Part B premium/contribution for folks that are approved.

IRMAA is a very good concept. However, it currently starts at $106,000 Single and $212,000 Married. It should start much lower, perhaps at 50% or 75% of the above amounts. Why should folks at income levels above 50% or 75% of current thresholds receive subsidized welfare benefits? They have the wherewithal to contribute a greater share by receiving a lessor subsidy. If you study the math regarding the premium/contribution as it relates to income, the lower paid folks are subsidizing the higher paid folks up to the point when IRMAA begins at $106 K Single and $212 K Married.

Lastly, I thought that some of the new folks in the current Administration may be problem solvers. However, it looks like the "same old same old". Maybe change for the better is in the future. Thanks for your positive support. 

[dd98032427]

Moving a procedure from an in-patient major operation to an outpatient status absolutely DOES save money. Shorter stay, maybe just a few hours instead of overnight. If in a clinic instead of a hospital, far less expensive. Less time spent by the staff. If it can be done safely, it's the way to go. Either way, Medicare pays. This way, it pays less.

[GailL1]

@dd98032427 - That is true - it does save money for the program in total but in this instance, we are talking about Part B premium - and in that regard, it increases Part B premiums.  

When under the inpatient classification, it was paid for out of the Medicare Trust Fund (Part A or HI Trust Fund).  A shift from Part A inpatient to Part B outpatient, decreases the cost to Part A but increases the cost to Part B and thus the Part B premium.  

Came back to Edit and add:  Because of this change, some people think they are getting shorted because making some procedures outpatient rather than inpatient, they also lose the rehab aspect of the inpatient coverage.  Now that does save a lot of money - agreed - but some are definitely not happy about it.  

[CBtoo]

Take it up with congress if you don't like what is happening in health care and get them to change how B is paid for - B is partly subsidized by the government for most of us, with that subsidy being reduced more and more as we hit certain income levels. And in advantage plans it may or may not be completely subsidized by the government.

Bringing down B by forcing people to be hospitalized when they don't need to just drives up issues for those people and drives up Medicare A's costs which will mean A will run out of money sooner than it already will. 

So you'd rather be hospitalized when you don't need to be just to bring down the cost of Medicare B? 

[GailL1]

@CBtoo “For most of us”  ??   Don’t think it is “most”.  

States pay for those who qualify for any Medicare Savings Program out of their Medicaid funds. 

Medicare.gov - Medicare Savings Programs  

I don’t understand what you mean by “with that subsidy being reduced more and more as we hit certain income levels”  because the state pays the going rate for any Part B premium.

Yes, there are income level eligibility qualifiers just like there are for any other Medicaid benefit - in most states there are also asset eligibility levels but in some states there are NO asset levels and in many the eligibility income levels are much higher.

KFF.org- 2025- Eligibility for Medicare Savings Programs for Qualified Medicare Beneficiaries (QMBs) 

MA plans may have a “giveback” program for some beneficiaries that qualify but this “giveback” amount does not go back into the Part B - SMI Trust Fund (Supplemental Medical Insurance Trust Fund)  This is the place where premium amounts collected sit until they are used.  

@CBtoo wrote - Bringing down B by forcing people to be hospitalized when they don't need to just drives up issues for those people and drives up Medicare A's costs which will mean A will run out of money sooner than it already will.

Would have to change the Social Security law to change the way Part B is paid for - 25% premiums from beneficiaries 75% from the government coffers with those who pay IRMAA covering a higher % of the cost.

SSA.gov - MEDICARE - Premiums: Rules for Higher-Income Beneficiaries  

Yes, making certain procedures outpatient rather than inpatient definitely helps to keep the cost down for Part A but it increases the premium price tags for Part B, which is what we are talking about here - Part B premiums.  

Since Part B and Part A are funded by two completely different funding sources it is not an even swap.  

What about a separate Part B payroll tax funding that people would fund during their working years, at least partially?  Might not help now but it would down the road cause we know this supplemental medical insurance (SMI - Part B) will go higher and higher; this would also save the government money by covering more Part B cost from a payroll deduction rather than the current method of beneficiary premiums (25%) and government match (75%).

What about widening the Medicare beneficiaries income levels that would be subject to IRMAA premiums?  

Perhaps instead of increasing them every year based on the cost of inflation, we could just set them at a level and leave them there - thus more and more beneficiaries would be subject to these type of premium sur-payments.

Just some other suggestions to hold down Medicare Part B premiums.

[CBtoo]

Only dual eligible people (eg have medicare and medicaid) or those with "help" have state funds used. They have them because of medicaid and medicaid is administered by the states. More people don't get this kind of help than do get this kind of help.

Look at the income levels and what you pay for medicare B premiums. It goes up as your income goes up. That means those who aren't paying the full price has the government paying the rest (the same with medicare D). You could lower the income levels that trigger increased medicare B premium costs. That would bring in more non-government money. I am sure you know how that would go over. Of course we could allocate less for medical care for vets and their families and use that general revenue money to pay to B to keep premiums down. I am sure that would go over well. (Not).

If Medicare cuts reimbursement rates too low many doctors will stop accepting medicare. Already in some parts of the country enough don't accept it such that the wait lists to get care from those who do is longer and some have a long wait to even get a PCP. Do you want that everywhere?

Stop inflation, stop upcoding... that would help. That is actually a rational action. Also what would work would be killing off people younger... that will bring your B down too since fewer older really sick people as people tend to get far sicker as they age (and save money on social security, Medicare A, B and D, SNAP, Medicaid, HUD...hmm the government would like that). Not an ideal solution from the point of view of the person who now has to pay more for premiums if they can't afford it so might choose to get less health care or not have B at all, but it would work. /sarcasm

The pot of money to pay for this is the same size, you are just talking about how you'd split it up. Everyone is in the same risk pool. If you pay more for some folks than others then either reimbursements need to go down or the pot of money needs to be bigger. Reimburse less and lose providers. Pay more and raise B premiums. 

[CBtoo]

Besides cost shifting, people are living longer so that will drive the costs up too. Inflation drives up the cost and a chunk of that inflation right now is being caused by the increased tariffs. Reading all the deals that are being cut with pharmaceutical companies so they can escape tariffs, the drug price cuts appear to not include Medicare prices - the focus is on private insurance and Medicaid. That isn't going to help either since some of those drugs are paid for via B. People could advocate that Medicare is included in the price cuts of meds that are being negotiated via tariff reduction.

I read in several places they are estimating the 2026 price of B will be around $206. Of course we won't know for sure until it is announced. 

[GailL1]

@CBtoo - Thanks for your suggestions - However . . . . 

If people are healthier as they live longer, it should not have too much of an effect especially if we have younger and hopefully healthier beneficiaries always coming into the program.

Now we do have those who have Medicare because of a disability (younger than 65) also adding to this Part B cost.  Perhaps we should have a separate Part B SMI just to see how this affects Medicare Part B - just for analytical  purposes. 

Part B is influenced  by medical inflation - but with CMS controlling how much  providers are paid for services, from physicians to DME, then that is already taken into consideration to a certain extent. 

The only drug prices that are covered under Part B are those that are given in a provider setting and covered by the Part B program.  The selected ones will begin negotiations in 2028.

KFF.org- 01/23/2025 - FAQs about the Inflation Reduction Act’s Medicare Drug Price Negotiation Progr... 

from the link ~

For selected drugs covered under Part B that are administered to individuals in provider settings, Medicare beneficiaries enrolled in Part B, including those in both traditional Medicare and Medicare Advantage plans, are eligible to receive the maximum fair price. (Part B drugs will not be selected for negotiation until 2028.)

I do not know how many of these would be affected by the tariffs.   I really doubt that the Part B premium that is being announced for 2026 would be that affected by any tariffs since they have not been in existence for very long.

Now we do have a huge problem with fraud in the DME area of remote monitoring and in supplies billed and never received.  I  personally think we need Medicare Contractor payers assigned to review all these claims BEFORE we pay them to verify their accuracy.  This is just a problem in Traditional Medicare since of course, Medicare Advantage plans scrutinize these claims before they are paid.

Now what would other think about some rules along the line that are used by private insurers and even in other countries and that is for those on Traditional Medicare to have to have a referral to a specialist from their PCP (personal care physician) - this would serve (2) important cost saving tactics.

1.  Encourage people to have a PCP - these type physicians can often treat many things without going to a higher priced specialist (2) Preserve the specialist care for those who medically need this sort of care.  This also helps the beneficiary too - with many specialist now requiring such a referral to better utilize their own time and another physicians referral usually helps to get the beneficiary into the specialist office faster than a self-referral.

In other countries, this is called having a “gatekeeper”  - and that is all that it is - a PCP that looks after you and oversees your care just so it is all moving in the best direction for the best care.  This PCP also knows all the meds you take so that there is no bad cross reactions or that one med is not cancelling out the other.  All kinds of benefits from having a PCP gatekeeper and it has been proven to save money just fro these actions.

I do not think that it is right that we can change procedures from hospital (Part A) to out patient (Part B) without some change in funds from one Medicare Part to the other - Government does want to control Part B cost because this is the area where they are paying the lion share of the cost.  Part B premiums pay for 25% of the Part B cost; the general fund of our US Treasury pays the other 75% - Of course, with those beneficiaries having a higher income paying a higher % of the cost - sometimes the full cost of both the beneficiary (25%) and the government’s share (75%) 

I am sure there are more practical changes - you may not think that some changes would save Part B a lot of cost - but multiply that by (now) 70 MILLION and it does add up.

Any other suggestions from anybody?

[CBtoo]

They are not necessarily healthier to live longer. They do use far more medical care and have more chronic conditions than younger people that require more doctor visits to keep in check what is wrong with them. Medical care has improved over the years. The cost of our B increasing has more or less matched the percent that reimbursements have gone up. 

One of the things that needs to be under better control so that will decrease the costs to B is the upcoding that goes on. That has also impacted the cost, thus what we pay for B. 

[GailL1]

ADDED

@CBtoo wrote . . . They are not necessarily healthier to live longer. They do use far more medical care and have more chronic conditions than younger people that require more doctor visits to keep in check what is wrong with them. Medical care has improved over the years. The cost of our B increasing has more or less matched the percent that reimbursements have gone up. 

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Part B premiums go up based on (1) usage (2) medical inflation

Since Part B is a pool of all beneficiaries in the Medicare Part B program, we should have a certain amount of balance between new incoming beneficiaries and older beneficiaries - But also as I mentioned, we do have the addition of those with SSDI also in this pool - It would be great to know how much this adds to everybody’s premiums just because they are many times high health care users.  

If these disabled folks pick a MAPD plan, then they have an added risk adjustment for Medicare Advantage insurers - maybe we should have the same in traditional Medicare?  

[CBtoo]

What - so you are saying sicker seniors should pay more for their medicare B? That sounds like a good idea. Then you'd kill off the sicker elderly who make too much for medicaid but not enough to pay a higher premium than everyone else. And the government would save on all sorts of things if the sicker people die younger (SS, Medicare A, B, D, SNAP, HUD, SS...).

[GailL1]

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@CBtoo wrote:

What - so you are saying sicker seniors should pay more for their medicare B? That sounds like a good idea. Then you'd kill off the sicker elderly who make too much for medicaid but not enough to pay a higher premium than everyone else. And the government would save on all sorts of things if the sicker people die younger (SS, Medicare A, B, D, SNAP, HUD, SS...).

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That isn’t what I said at all - I said “ But also as I mentioned, we do have the addition of those with SSDI also in this pool - It would be great to know how much this adds to everybody’s premiums just because they are many times high health care users. “

IOW, a separate data - one for 65 and over and another for under age 65 - maybe even break those that are very young on SSDI into a separate category - they have not paid in as much during their working days into the Part A Trust Fund and even though they pay the same Part B premium, they may use lots more of it for a much, much longer term.  I am just saying that perhaps there does need to be some equalization based on need for those less than 65.

SSA.gov - Disability Benefits  

With this data, perhaps we could come up with a way that a spouse who is disabled and is not covered could pay into the system and get at least some medical benefits - which right now they cannot.  

[CBtoo]

The baby boom generation breaks everything we touch because we are such a huge population bubble. As boomers age the number of younger people with Medicare B will proportionally be less. That will drive premiums up too. 

The money for A and B comes from the same sources whether they are a straight B or part of an advantage plan. IF what you say is true - that medicare advantage gets "paid" more for administering B - then maybe we should get rid of advantage plans to save money and bring premiums down. LOL

[GailL1]

@CBtoo wrote . . . . The money for A and B comes from the same sources whether they are a straight B or part of an advantage plan. IF what you say is true - that medicare advantage gets "paid" more for administering B - then maybe we should get rid of advantage plans to save money and bring premiums down. LOL

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Medicare Advantage insurers are paid by CMS  (1) a flat cost for every beneficiary that buys their plan - from Part A and Part B based on what the average cost is for the program  (2)  IF the beneficiary is high risk, which means they are a beneficiary that is gonna cost more than the average beneficiary then CMS  pays them a risk adjustment so that the MA insurer does not discriminate against them.    Been that way since the beginning of MA plans,  The only thing that has been in disagreement is how this measure has been assigned - now, beginning in 2026, any high risk classification has to be documented by the beneficiary’s  medical file.  

There are always those that cost more than others - the disabled, those with lots of chronic diseases, those who have other specific diseases that are costly to treat.

[CBtoo]

YOu said, "The only thing that has been in disagreement is how this measure has been assigned - now, beginning in 2026, any high risk classification has to be documented by the beneficiary’s  medical file.  "

And that is one thing they are doing to address upcoding to get more money for the visit. 

[GailL1]

@CBtoo 

How would we control upcoding without adding more prior approvals or pre-claim reviews?

CMS.gov - Prior Authorization and Pre-Claim Review Initiatives 

Seems when something like this is proposed, many beneficiaries react very negatively.

What about “gatekeeper” and a required referral from one’s PCP before seeing a specialist like I described above.  These type things do definitely save money so perhaps they would keep down Part B premiums for beneficiaries.

[CBtoo]

Gatekeeping doesn't control upcoding. That just prevents or delays seeing specialists for appointments that, in most cases, are needed. Upcoding is when they code for a longer visit than the person had or add diagnoses to the coding or say the level of the disease is more serious, or even code for things they don't have (that is what advantage plans are under investigation about - as well as denying too many necessary specialist referrals). Gatekeeping isn't going to stop that. 

[CBtoo]

Controlling upcoding - well they are working on that with advantage plans as they are the biggest guilty party with that. I think I read they are using AI to review claims and flag those that need looked at more carefully. I have no idea what else they are doing and I'd bet they won't disclose that either as if they did then some unethical providers and systems would look for ways to scam that.

[GailL1]

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@CBtoo wrote:

Controlling upcoding - well they are working on that with advantage plans as they are the biggest guilty party with that. I think I read they are using AI to review claims and flag those that need looked at more carefully. I have no idea what else they are doing and I'd bet they won't disclose that either as if they did then some unethical providers and systems would look for ways to scam that.

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I disagree that MA plans are the biggest culprits - in fact, just because they are private companies, they have the incentive to watch their cost much better than traditional Medicare and because they can with people assigned just for this duty.  

MAPD plans can refuse to pay fraudulent claims - they rarely if ever have DME fraudulent claims which are rampant in Traditional Medicare.  Same with upcoding - they scrutinize their claims and compare them to what is medically necessary to avoid upcoding or a doc ordering test and procedures that are not medically beneficial based on best practices.

I am hoping that we will be so lucky when the new test for preapprovals begins in those (6) states on (17) different procedures that CMS knows are low value based on the Medicare Coverage determinations.

CMS.gov- Medicare Coverage Determination Process 

CMS.gov- PRESS RELEASE 06/27/2025 - CMS Launches New Model to Target Wasteful, Inappropriate Service... 

Actually, this is nothing new - some procedures have been under review by Medicare since 2020 - this is just expanding the program with other low value or Medicare UNapproved services for these (6) states and these (17) different outpatient procedures.

Affected states

Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. 

Affected procedures (17 total)

• Skin and Tissue Substitutes
• Nerve Stimulators (including electrical and deep brain)
• Epidural Steroid Injections (excluding facet joint injections)
• Cervical Fusion
• Knee Arthroscopy (for knee osteoarthritis)
• Incontinence Control Devices
• Blepharoplasty
• Botulinum Toxin Injection
• Rhinoplasty
• Panniculectomy
• Vein Ablation
• Implanted Neurostimulators
• Cervical Fusion with Disc Removal
• Osteogenesis Stimulators
• Facet Joint Interventions
• Repetitive Scheduled Non-Emergent Ambulance Transport
• Power Mobility Devices and Accessories 

[CBtoo]

Well the federal government seems to think they are the biggest culprit (although not every advantage plan engages in that to the extent that some do). They are specifically going after advantage plans with respect to that. This is why they have added rules to try to increase the documentation that supports "higher" codes. 

Since you like citations read this:

https://www.aarp.org/advocacy/medicare-advantage-excess-billing/#:~:text=9,would%20save%20the%20gove...

And this:

https://www.beckerspayer.com/payer/insurers-brought-in-50b-through-medicare-advantage-coding-wsj/

And this:

https://natlawreview.com/article/closer-look-proposed-changes-medicare-advantage-no-upcode-act

[GailL1]

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@CBtoo wrote:

Well the federal government seems to think they are the biggest culprit (although not every advantage plan engages in that to the extent that some do). They are specifically going after advantage plans with respect to that. This is why they have added rules to try to increase the documentation that supports "higher" codes. 

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 Of course, MA plans have had their problems especially in this risk adjustment procedure.  But remember, MAPD plans are controlled by the rules that CMS enforces.  This has been going on for sometimes and I we knew it was happening - court cases proved it but yet Congress nor CMS did not act.  That is why the new administration is taking steps to curtail this - by now requiring that any higher risk adjustment has to be documented in the beneficiary’s medical records. (one of the reasons why we are seeing such turmoil in the MAPD marketplace for 2026)  Lots of new rules and requirements.

That is a slightly different type of “upcoding” than what  happens at the provider level - but, yes both do increase medical cost.

Per the NIH - Upcoding in Medicare has been a topic of interest to economists and policy makers for nearly 40 years. Upcoding is a term that is not defined in the regulations but is generally understood as “billing for services at a higher level of complexity than the services actually provided or documented.

For this type of upcoding at the physician level, MAPD plans do a much better job of controlling this than traditional Medicare.

oig.hhs.gov - Physician Relationships With Payers- UPCODING in Medicare and Medicaid 

from the link ~

Upcoding

Medicare pays for many physician services using Evaluation and Management (commonly referred to as "E&M") codes. New patient visits generally require more time than follow-up visits for established patients, and therefore E&M codes for new patients command higher reimbursement rates than E&M codes for established patients. An example of upcoding is an instance when you provide a follow-up office visit or follow-up inpatient consultation but bill using a higher level E&M code as if you had provided a comprehensive new patient office visit or an initial inpatient consultation.

The link gives several examples of how this occurs and it does occur on a pretty regular basis - a provider may want to make a few buck more so they upcode a beneficiary’s visit from a minimal timing visits to one that is of a higher time value - 

I think this sort of upcoding is gonna be a lot harder to keep a handle on it that the MAPD plans risk adjustment problems - because they watch their claims better than traditional Medicare.  

Maybe than even what Traditional Medicare can do under the current way that it is done.  

[CBtoo]

And it is advantage plans that have been getting away with upcoding and now the government is coming after those that are doing it. End of story. It doesn't matter what happened in the past. 

They'd be watching original medicare if the level of problem was as high or almost as high as advantage plans. I'd imagine the government also checked on what original medicare was doing as well, didn't find the level of fraud and so focused on where the biggest problems were. 

And getting rid of upcoding will mean less money is being reimbursed for a visit which is will help keep costs down thus, if we are very lucky, B premiums won't rise as fast.

[Tonster521]

@CBtoo, As I understand the Medicare policy/procedures established by CMS, there is a difference between the Medicare Risk Adjustment paid to Medicare Advantage Plans (MAPs) and "upcoding" which is fraud and probably occurs in both Medicare and MAPs (including HMOs). There have been  other postings on this Forum and some fairly decent threads wherein folks voiced their concerns after several journalists reported aggregate payments to MAPs using the word, "upcoding" rather than Medicare Risk Adjustments. If you are interested in the policy/procedure for the CMS Medicare Risk Adjustment, I suggest you search via Google or any other search software to learn the complexities of the Medicare Risk Adjustment policy/procedure which has been in existence with the CMS for at least 20 years. From a financial perspective, I do not know of any insurance company or financial institution that will provide the scope of Medicare Part B coverage for $185/month. I believe Gail1 and other have already pointed out that we pay/contribute approximately 25% of the Part B estimated cost ($740/month) and Medicare receives the other 75% from the U.S. Treasury General Fund (aka the taxpayers). I understand your comments. However, I believe folks need to look at issues on a level field (apples to apples). Why would one provision of the medicare program (Part B) receiving a 75% subsidy and other provisions (MAPs including HMOs) receive 0% ($0.00)? The Medicare Risk Adjustment policy/procedure is the CMS answer to the above. I am sure you are clever enough to know that whatever services (and their related costs) provided by MAPs/HMOs are not paid (savings) to the Part B provisions. 

[CBtoo]

The other issue, as far as I am concerned is that medicare advantage plans get given more money to support their purpose of doing "wellness" and trying to prevent illness. The studies I have seen is that there is no difference between advantage plans and original medicare on the metrics they were looking at which is unfortunate. 

[CBtoo]

I am sure upcoding occurs in both too, and shouldn't exist at all,  however the articles I gave the urls for documents that when looking at both original medicare and advantage plans the rate of upcoding is MUCH higher in advantage plans than with original medicare.

[Tonster521]

@CBtoo, I am not sure if you are responding to my reply or to Gail1. Anyway, the CMS procedure for developing payments to MAP requires a risk assessment (health). Based on that payment, the MAP takes the risk for treating the patient, healthy or not healthy. Many believe this is upcoding. This is a risk assessment procedure designed by CMS. Obviously, an insurance company has to do a thorough assessment during this risk assessment procedure and make sure any and all medical issues are documented. It should be noted that the CMS has audited the risk assessment procedures for years and have not found widespread fraud (upcoding) as certain journalists have alleged. 

[CBtoo]

That's not what I am talking about. We are talking about two different things.