A bipartisan group of four senators is advocating for stricter provisions under the proposed No Unreasonable Payments, Coding, or Diagnoses for the Elderly Act to address insurer upcoding, according to a March 30 letter sent to CMS Administrator Mehmet Oz, MD, that was obtained by Bloomberg Government.
In January, CMS proposed its 2027 Medicare Advantage rate notice, which would exclude diagnoses from unlinked chart reviews. However, the recent letter — signed by Sens. Jeff Merkley, D-Ore., Bill Cassidy, MD, R-La., Tina Smith, D-Minn., and Roger Marshall, MD, R-Kan., — warned that “insurers may seek to recapture lost diagnoses by linking chart reviews to specific encounters, potentially dampening the effect of the proposed change to exclude diagnoses from unlinked chart reviews.”
The letter also said Congress should have HHS alter the risk-adjustment methodology to include two years of diagnostic data instead of just one to better understand conditions that are not consistently reported every year. The letter also asked HHS to modify payments “based on the true coding pattern differences between MA and fee-for-service Medicare,” citing the Medicare Payment Advisory Commission’s 2026 estimate of increases in payments to MA plans.
The rate notice pitched a nearly flat 0.09% increase in MA payments for 2027, prompting concerns over steeper premiums and less robust benefits. But, in 2025, MedPAC projected that $40 billion in Medicare overpayments resulted from coding intensity, the letter said.
Dr. Cassidy and Mr. Merkley introduced the No UPCODE Act in March 2025. The legislation has not passed Congress and was met with insurer backlash in 2025 over Medicare funding concerns.
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