House Democrats introduced a bill July 1 targeting Medicare Advantage overpayments.
Under the bill, HHS would need to exclude or adjust diagnosis codes that “are most likely to be subject to coding variation by Medicare Advantage plans,” limiting possible upcoding. Diagnoses from chart reviews and health risk assessments would not be considered while adjusting payment, either.
The bill would end the “failed” quality bonus program after 2028 and adjust for favorable selection, according to a news release from Rep. Lloyd Doggett, D-Texas.
The legislation would also set timelines for risk-adjustment audits and lower MA payments by 0.02% to help fund these audits. There would be no judicial review of these audits, as well. Audits would become even more consequential as HHS gains the ability to extrapolate findings to the whole MA population.
“Despite their early claims of greater efficiency and lower costs, Medicare Advantage has never saved a penny. It actually costs taxpayers more each year while offering consumers less,” Mr. Doggett said. “This unjustified, costly advantage private Medicare Advantage insurers receive must be ended to save taxpayers and end the disadvantage for traditional Medicare.”
A March report from the Medicare Payment Advisory Commission estimated MA payments will be 14% greater than fee-for-service Medicare in 2026. The Better Medicare Alliance, an industry group, has historically pushed back against MedPAC’s methodology.
The quality bonus program has been under pressure in recent months, as well, due to litigation that drove a recalculation of MA star ratings, affecting bonuses.
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