Bill Introduced to Combat Medicare Advantage Upcoding

The legislation aims to reduce overpayments to Medicare Advantage (MA) plans.

A pair of U.S. Senators have put forth a bill to oppose upcoding in MA by eliminating incentives for plans to overcharge.

The No Unreasonable Payments, Coding, or Diagnoses for the Elderly Act, or No UPCODE Act, has been introduced by senators Bill Cassidy (R-La.) and Sen. Jeff Merkley (D-Ore.) in the midst of MA plans taking heat for receiving billions of dollars in overpayments.

CMS has released its Medicare Advantage Risk Adjustment Data Validation final rule to claw back those overpayments, but the rule will only apply to audit findings beginning with the payment year 2018.

"Federal audits have found that taxpayers have been overpaying bad actors running Medicare Advantage plans by billions of dollars every year, threatening the stability of both Medicare Advantage and traditional Medicare," Merkley said in a statement. "This fraud has to end."

The No UPCODE Act strives to fight that fraud by:

• Switching to a risk-adjustment model that uses two years of diagnostic data instead of just one.
   
• Restricting the use of old or unrelated medical conditions to determine cost of care.
   
• Ensuring Medicare is only charged for relevant treatment.
   
• Closing the gap between how patients are assessed under MA and traditional Medicare.

With MA growing at record rates, it's vital MA plans are kept in check so beneficiaries and taxpayers aren't negatively affected.

"Medicare is going insolvent in four years," Cassidy said. "The challenge is preserving that which is good while squeezing out waste. This bill is a step in that direction."