Senators float 'no upcode' act to crack down on Medicare Advantage overpayments

Two Senators are introducing legislation aimed at reducing Medicare Advantage overpayments. 

Sen. Bill Cassidy, MD, a Louisiana Republican, and Sen. Jeff Merkley, an Oregon Democrat, introduced the No Unreasonable Payments, Coding, or Diagnoses for the Elderly, or No UPCODE, act March 27. 

The proposed legislation would target upcoding through several mechanisms, including 

  • Shifting to a risk-adjustment model that uses two years of diagnostic data instead of one year. 
  • Limiting the ability to include old or unrelated medical conditions in the cost of care.
  • Ensuring Medicare is only charged for treatment related to relevant diagnosis codes.
  • Closing the gap between how patients are coded in traditional Medicare and Medicare Advantage.

In a news release, Dr. Cassidy said the bill is a step to preserve "that which is good while squeezing out waste." 

Nearly every major payer has been accused of or settled allegations of upcoding — making Medicare Advantage patients appear sicker than they are on paper to receive more payments from CMS.  

Mark Miller, PhD, executive vice president of healthcare at Arnold Ventures, told Becker's Dr. Cassidy and Mr. Merkley's bill follows the Medicare Payment Advisory Commission's recommendations for preventing overpayments. 

Dr. Miller said the problem of upcoding cannot be solved by CMS alone. 

"This issue is not going to go away. I think it's interesting that Cassidy and Merkley have introduced a bill to do just that," Dr. Miller said. "I think if this is going to happen, it has to be the administration and the Congress working together." 

Copyright © 2023 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Webinars

Featured Whitepapers

Top 40 articles from the past 6 months