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]

@CBtoo, it is my interpretation of the various articles that you and others have provided on another thread, the word, "upcoding" which is a form of healthcare fraud has been used/exchanged for the words,"medical risk assessments" or MRAs. I am not sure which activity you are commenting on. I am sure you as well as others know that all of us older folks develop health issues over time. In fact, very few of us are without a health issue. So, if one is in the healthcare business, how do you fund/pay for healthcare which is risky. Some folks need more healthcare than others. One approach from the the CMS, Medicare Part B, is have an Uncle Sam with unlimited access to money via taxes and/or issuing debt (i.e., treasury securities, etc.). In an attempt to reduce that Medicare Part B unlimited risk exposure, Uncle Sam elects to transfer some of that risk to another institution/payor such as an insurance company, a health maintenance organization, etc. So, how does the CMS find someone else to take on that risk? Will they do it for $185/month? The answer is clearly "No". There has to be an equitable method for allocating some percentage of the estimated cost ($740/month) for Medicare Part B which includes acute and chronic healthcare treatments. The MRA procedure was created by CMS to provide an equitable method for paying someone to take on the risk of providing healthcare to a risky group of folks who have known and unknown morbidity (health issues). The issue is trying to determine future needs for healthcare. Some organizations are very good at MRAs and stay viable. Others are not and generally reduce their risk exposure to healthcare or close down. 

I suppose there is a skill that is needed for MRA. Some folks may allege that MRA is upcoding which is healthcare fraud. I agree that when there is money on the table upcoding can and will occur. However, the MRA procedure is audited and as Gail1 pointed out will be looked at more closely starting in 2026.

Lastly, the amount of money that is transferred to Medicare Advantage Plans has "raised an eyebrow". One reason is that more and more folks are electing the managed care approach (MAP/HMO). I do not know if that is the desired outcome that the CMS is after. Are the majority of folks who elect managed care (MAP/HMO) healthier than the folks that elect Medicare Part B? One would need to review utilization of all approaches and correlate that to folks and their individual elections. https://www.nhcaa.org/events/upcoding-a-common-medical-fraud-exposed/ I think this link will help with the definition of upcoding.

[CBtoo]

1) Some pay more than $185/months due to their income

2) The government brought some of this on themselves allowing the for profit companies to decide how much commission they will pay agents to sign someone up for an advantage plan, a supplement or D (they'd remove the incentive to sign people up for advantage plans if all commissions were the same across companies and the commission for an advantage plan = that of a supplement +D). The government pays companies more per person for advantage plans due to the supposed wellness focus (which has not panned out). So what do companies do? Pay more than double in commissions to sign people up for advantage plans since they get more per person. What then do agents do? They sign more people up for more advantage plans since they get paid far more to do so. That has led to the explosion in advantage plan enrollments. 

3) Generally more healthy people sign up for advantage plans since while they are healthy then health care costs them less. (I a ignoring those who are dual eligible in this as their health care is very close to free for them). BUT when they are sick the maximum out of pocket for an advantage plan is far higher than supplement and D premiums plus those out of pockets. Then, if they pass medical underwriting, or live in  a state that allows them to do this annual under various different sets of rules,  they switch. That funnels sicker people into supplements which raises those costs. If they can't switch then their health care costs go through the roof and some find they can't use the providers they now want to use because they are out of network. Since many advantage plan providers get money back for B premiums this just adds to the financial pressure people actually use financial plans. I am reasonably sure the profit need of for profit companies under those circumstances has lead to the reduction in shiny things (eg all the freebees), reduced to no commission to agents to sign up people, smaller networks, and exiting the market completely. (Of course when your plan vanishes you have guaranteed issue to sign up for a supplement if you want - no need to pass medical underwriting and the sicker people will do that as in the end they will save money (if they don't have medicaid as well) but those who still are reasonably healthy will just switch to another advantage plan. This helps advantage plans to "get rid" of sicker patients. 

3) 2026: commissions have been cut to zero for many advantage plans, many D's and a few supplements. On a list of agents I read many have said, "X company is dead to me because they aren't paying commission.". So they aren't planning to tell customers about those plans, or any plan, from those companies. With all the changes, PPO's vanishing in many markets replaced by HMO's, etc. there are going to be major problems with this sign up period for people who use many agents finding out about which program is "best" for them during this sign up. SO MAKE SURE YOU LOOK AT MEDICARE.GOV TO ACTUALLY SEE WHAT ALL YOUR CHOICES ARE THIS YEAR.

4) And what we are seeing is what happens when our medical care model is for profit rather than treating it as something everyone should be able to have.

5) Outsourcing the administration of medicare A and B (and the future potentially privatizing social security as well will likely mean this will happen as well) to for profit entities means less money available for the actual purpose of those programs because a big chunk of money has to go to the stockholders. Likely this will mean more of the problems some people are currently are experiencing with advantage plans with respect to limited networks due to some providers no longer accepting them (for example this year some agents are posting that the only advantage plans available in some zip codes don't include the major provider system which is really going to cause issues for those who already have those plans and can't switch to original medicare because they fail medical underwriting as they will have long travels for in network care), the referral denials, delays in referrals being approved, etc. 

6) Will the way advantage plans are going to be audited with respect to upcoding work? Have unintended consequences? Will it add extra work for the health care systems? Will it result in systems not wanting to deal with it and opting out of accepting advantage plans? Will the auditors use AI to do this (if they do research has indicated at AI is good at narrow, specific and often simple things, it fails with people with complex medical issues - as a result it may well mean providers have to spend even more time documenting a pile of stuff wrong with people that the visit wasn't about but affects their decisions or have to appeal rejection of justifiable higher levels of care codes, etc. will unnecessary tests be ordered, like a local for profit emergency room does to "justify" upcoding happen? Systems may drop out due to that). Will there be other unintended circumstances? That we won't know until the auditing is actually in place. 

[Tonster521]

@CBtoo, Based on your multiple comments on this thread, I am not sure if you do not view Managed Care (via Medicare) as a viable program or are looking for negative issues with how the CMS has implemented Managed Care with private (non-governmental) for profit organizations. I realize Gail1's post asked for ideas on how to hold down Medicare Part B premiums/contributions which includes both Fee For Service (FFS aka Part B coverage) and Medicare Advantage (MA including PPO, HMO, and other acronyms). All of these approaches that CMS offers are created and developed to provide welfare benefits to insure folks (aged and disabled) against costly healthcare expenses. Is any one approach better than the other? Does any one approach effectively promote high quality medical

care? Who knows? The CMS continues to provide both approaches along with other cost saving incentives, some that work and others just increase costs. It is abundantly clear that folks electing the FFS approach need Medigap coverage that will provide benefits due to Parts A and B lack of coverage. On the other hand, MA including some HMOs have stop loss coverage that provides 100% coverage after certain costs are incurred by the individual. Each approach will appeal to different folks. Some do not object to paying additional premiums for Medigap coverage year after year whether they use such coverage or not. Others do not object with paying some of their healthcare expenses as long as there is stop loss coverage. 

The two issues that appear in multiple studies of MA Plan costs are intense medical coding activities and favorable selection. MA Plans have an incentive to report every diagnosis for an enrollee. FFS providers are more likely to focus on the significant diagnosis that is the primary for the visit. Because of this, FFS providers may not be reporting all diagnoses in FFS Medicare. Based on my understanding of the CMS Medical Risk Adjustment model which is developed using FFS claims data, it is inevitable that the intense medical coding will increase payments to MA Plans over FFS spending. Also, the continued growth of MA Plans may be challenging for the benchmarks because beneficiaries remaining in FFS may be a higher risk that risk adjustment cannot capture. The initial concept dating back to 1985 was that payments were targeted to be 95% of FFS payments. Today, it is estimated to be about 122%. Quality bonus payments increase MA Plan payments for about 74% of MA enrollees, but does not effectively promote high quality care which is difficult to measure. I do not know why the CMS has a Quality Bonus Program or how does it measure quality.

I am including a link from Brookings which may help understand financing Medicare. https://www.brookings.edu/articles/how-does-medicare-work-and-how-is-it-financed/#:~:text=and%20Mone.... Brookings raises another issue which most folks seem to miss; namely, Medicare Part A. The Medicare Part A Trust is projected to be depleted in 5 to 6 years. Remember, Part B is funded approximately 75% from the General Fund (income taxes, etc.). So, there will be a source of revenue as long as folks pay taxes. This is why higher income folks are required to pay IRMAA which brings some fairness to the tax burden of Part B. Think about a married retirees earning $60,000/year. Their annual Medicare premium/contribution is $4,440 ($185 X 24) or 7.4% of their income. Compare to another married retirees earning $211,000/year which is just below the threshold wherein IRMAA starts ($212,000). This couple pays the same $4,440, but that represents only 2.1% of their income. Why should lower income folks subsidize higher income folks? Even with IRMAA payments, higher income folks are not paying their fair and equivalent share. I realize that I presented a "big picture" view. However, it should be abundantly clear that Part B is financed by taxes based on income offset by contributions from folks based on a projected amount of Part B expenses that for the majority of folks is not based on their income. I am not sure what the amount of commissions that insurance agents earn have to do with the Part B contribution.

[GailL1]

@Tonster521 

CMS did change the documentation required for a higher risk assessment for 2026 - any added diagnosis has to be documented in the physicians notes on the patient.  They are suppose to catch it during the audit - but the audit is very, very far behind - hopefully getting caught up now.

CMS.gov -Medicare Advantage Risk Adjustment Data Validation Program 

ABOUT THE AUDIT PROGRAM

A CMS Strategic Pillar is to protect the Medicare, Medicaid and Marketplace programs for future generations by serving as a responsible steward of public funds. The Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program is CMS' primary way to address overpayments to Medicare Advantage Organizations (MAOs). During a MA RADV audit, CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollees' medical records. If diagnoses are unsupported by the medical records, CMS may collect overpayments. MA RADV audits occur after the final risk adjustment data submission deadline for the MA contract year.

Edited to add:

CMS.gov- 05/25/2025 - CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage... 

Currently, CMS is several years behind in completing these audits. The last significant recovery of MA overpayments occurred following the audit of payment year (PY) 2007, despite federal estimates suggesting MA plans may overbill the government by approximately $17 billion annually. The Medicare Payment Advisory Commission (MedPAC) estimates this figure could be as high as $43 billion per year. CMS’s completed audits for PYs 2011–2013 found between 5% and 8% in overpayments.

To address this backlog, the Trump Administration has introduced a plan to complete all remaining RADV audits for PY 2018 to PY 2024 by early 2026. Key elements of the plan include:

• Enhanced Technology: CMS will deploy advanced systems to efficiently review medical records and flag unsupported diagnoses.
• Workforce Expansion: CMS will increase its team of medical coders from 40 to approximately 2,000 by September 1, 2025. These coders will manually verify flagged diagnoses to ensure accuracy.
• Increased Audit Volume: By leveraging technology, CMS will be able to increase its audits from ~60 MA plans a year to all eligible MA plans each year in all newly initiated audits (approximately 550 MA plans). 

[GailL1]

@CBtoo 

For the risk adjustment, that seems to be taken care of now since the adjustment has to be founded in the providers notes as validation of higher risk.

[CBtoo]

However exaggeration in patient notes will still make "upcoding" seem legit as the exaggerated "documentation" will make it seem that the patient is sicker. Of course they will need to be more careful in how they do this because if the patient reads the visit notes they may call out the provider on what is in there. I think likely this will cut down on it but not get rid of it. Also it depends on what percent of the visits are monitored for this. If it is low enough then the risk of being caught is minimal.

[GailL1]

It would have to be something that is diagnosed and in the chart - to add more illnesses - not just complaints - well, not until a diagnosis anyway.

The “diagnosis” is the confirmed difference here - to get a diagnosis, the doc has to figure it out based on test, labs, examinations.  That’s for the MA plans and their validation of the risk assessment.

Now for traditional Medicare - the upcoding is more subtle - they spend 15 minutes with you and code it as 30 minutes or an hour.  Or the provider may want you to get tested by thyroid deficiency or in my case, an over active one - so he orders labs that go to a facility that he is part owner.  Or you get a diagnosis and then he orders the newest biological med, very high price because he owns stock in the drug company.  This may get nipped in the bud by the Part D plan sponsor if they ask for step-therapy or make the suggestion to the beneficiary that another generic may do - if the doc will prescribe it.

That’s why CMS makes them sign a disclosure statement.  But the system will never catch it all - but the big stuff maybe - back in about 2012, CMS use to have a database of PCP in Traditional Medicare with the medications that they most often  prescribed to check for this and also for any other type in fracture by the PCP in prescribing.

[CBtoo]

Gail said, "It would have to be something that is diagnosed and in the chart - to add more illnesses - not just complaints - well, not until a diagnosis anyway."

Well I have all sorts of diagnoses in my medical records I don't have. It's like playing wack-a-mole getting them out and getting them to stay out. Just last week I had to correct a provider and ask her to fix my visit notes and then resubmit them for a corrected reimbursement.

In my case they see I am taking a med off label (not realizing I am taking it off label) and presume because of taking that med I have that "usual use of the med" disease. Umm nope. They presume I have a fail medical underwriting problem on top of that. 

[GailL1]

@CBtoo 
You are not suppose to have a diagnosis in your chart unless there have been exams, tests, images or labs that have been used to do the diagnosis.  

That is why I review mine as my visits and services are documented - there is a history of the test, images, exams or labs in these documents and the conclusions drawn - sometimes more than one type to reach any diagnosis - I have few diagnosis’s - HBP that is now under control and really never got that high anyway and an overactive thyroid that I have always had -

The source of my headaches have still not been found and I continue to do occasional consults on them - now, I am keeping a diary when they occur and also record all kinds of other stuff like what I ate, barometric pressures  and other weather conditions.  

So now they are only recorded as idiopathic.

Sorry you are having such a problem with your documentation.  Just have never had that problem. 

[CBtoo]

What people are supposed to do and what they actually do often are different. If upcoding is deliberate then what is recorded in your medical record can be fictitious or exaggerated. Heck plenty of doctors fill out crap stating they examined things they didn't. 

[SummerOnTheWay1]

[10/19/25]

@CBtoo , are you talking about the NOTES in MyChart "online" profile? That is what BOTH patient & doctors (medical staff) use in my location in Virginia. As I age, I do "read" my After Visit Notes & Test Results. Lol, alot I have to Google. Thinking about purchasing a Medical Dictionary. 🙄 

➡️[*** 

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@CBtoo wrote:

However exaggeration in patient notes will still make "upcoding" seem legit as the exaggerated "documentation" will make it seem that the patient is sicker. Of course they will need to be more careful in how they do this because if the patient reads the visit notes they may call out the provider on what is in there. I think likely this will cut down on it but not get rid of it. Also it depends on what percent of the visits are monitored for this. If it is low enough then the risk of being caught is minimal.

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[CBtoo]

@SummerOnTheWay1 yes that is what I am talking about. There are sections in that which are used by the coders to figure out what codes to assign.

[CBtoo]

Yes. Although when you look at your Medicare EOB's that only shows some of the codes used and googling the codes doesn't necessarily mean you will know if there is upcoding. If you are trying to decide if what is in the medical record visit notes is exaggerated (to justify upcoding - of course you may not know if you have been "upcoded" to being with) you can at least see if what is written there seems "accurate".

It doesn't show a lot of the medical ones. You have to hunt for them (and I can't find the url to find them on medicare.gov. Very irritating if you want to pass medical underwriting as the codes you can't find easily are the ones they look at. 

[GailL1]

@CBtoo 

Beneficiaries can ask for a copy of their PCP’s exam code sheet (or what ever they call it) - What he gives to his billing office with the codes / diagnosis’s/ test/ treatments/ even the type of exam - 

I get a copy of it at my occasional visits and then hold it until the claim comes thru on the Medicare MSN - I keep these as a record of the when, what and outcome.