Improving Medicare Advantage Payment Accuracy: Secretary Xavier Becerra Reaffirms Commitment to Reform

Medicare Advantage Faces Scrutiny Amidst Calls for Reform

October 16, 2025

Dr. Mehmet Oz, the current Administrator of the Centers for Medicare & Medicaid Services (CMS), recently addressed the future of Medicare Advantage (MA) during a forum hosted by the Better Medicare Alliance. His remarks underscored the challenges of reforming the program while maintaining support from the influential insurance industry. Oz affirmed his commitment to the program’s potential, but also acknowledged existing issues surrounding improper payments and barriers to care.

The Growth and Appeal of Medicare Advantage

Medicare Advantage has experienced substantial growth, now covering approximately 35 million Americans – over half of all Medicare beneficiaries. This growth is fueled by attractive supplemental benefits and often lower upfront costs compared to traditional Medicare. Recent studies, including one from UnitedHealth Group in May 2025, suggest potential positive impacts on health outcomes for those enrolled in full-risk MA plans.

However, this popularity is coupled with emerging concerns. While enrollees may experience lower costs, the program’s expenses for the federal government are significantly higher than traditional Medicare. Congressional advisory group MedPAC estimates a $84 billion cost difference for the current year alone.

Upcoding and Payment Discrepancies

A important contributor to these higher costs is the practice of “upcoding,” where insurance plans may intentionally code members with more severe conditions to receive higher reimbursement rates.This practice, intended to compensate insurers for covering sicker populations, has created an incentive to identify and code as many possible conditions as possible, irrespective of treatment necessity.

ongoing Regulatory Efforts and Court Challenges

The Biden administration previously implemented policies to curb these perceived abuses in the MA payment system, a path Oz has, to some extent, continued. This spring, CMS announced plans for more rigorous audits of MA insurers to recover overpayments. While Oz supports these audits, a recent court ruling in October 2025 temporarily blocked a key component of the audit plan, following a challenge from Humana. Oz maintains the importance of verifying insurer practices to prevent systemic issues.

Furthermore, concerns have been raised regarding home health risk assessments, used by insurers to understand member needs. While intended to proactively address health concerns, these assessments are also linked to inflated coding practices, according to multiple studies. Oz emphasized the need to focus on treating identified problems, not simply coding them for financial gain.

A Collaborative Approach to Reform

Despite the challenges, Oz expressed optimism about the future of Medicare Advantage.He indicated a preference for working collaboratively with the private sector to implement reforms, rather than through unilateral government action, in line with earlier pledges to roll back restrictive prior authorization practices. He believes that industry collaboration, coupled with ongoing government oversight, can unlock the potential of MA to improve both cost and quality of care.

Here is a table summarizing key points:

Area of Concern	Description	Potential Solutions
Upcoding	Inflating diagnoses to increase reimbursement rates.	Enhanced audits, stricter coding guidelines.
Prior Authorizations	requiring pre-approval for certain services, potentially delaying care.	Streamlined processes, reduced administrative burdens.
Access to Care	Narrow networks and utilization management limiting beneficiary choices.	Network adequacy standards, improved openness.
Federal Costs	MA costing the government more than traditional Medicare.	Payment model adjustments, more accurate risk adjustment.

Did You Know? Medicare Advantage enrollment has more than doubled in the past two decades, reflecting a growing preference for managed care options among seniors.

Pro Tip: If you’re considering a Medicare Advantage plan, carefully review the network, coverage details, and prior authorization requirements to ensure it meets your healthcare needs.

Understanding the Future of Medicare Advantage

the ongoing debate surrounding Medicare Advantage highlights the complex challenges of balancing cost control, quality of care, and beneficiary access. As the program continues to evolve, it will be essential for policymakers, insurers, and healthcare providers to work together to ensure that MA delivers on its promise of affordable, high-quality healthcare for seniors. The trends towards value-based care and preventative services are likely to play a significant role in shaping the future of MA. The increasing adoption of telehealth and remote patient monitoring may also offer opportunities to improve access and reduce costs. The interplay between regulatory oversight and private sector innovation will define whether Medicare Advantage can truly optimize the healthcare experience for millions of Americans.

Frequently Asked Questions About Medicare Advantage

• What is Medicare Advantage? Medicare advantage is a type of medicare health plan offered by private companies approved by Medicare.
• How does upcoding effect Medicare Advantage costs? Upcoding inflates reimbursement rates, leading to higher overall program costs for the government.
• What are prior authorizations in Medicare Advantage? Prior authorizations require pre-approval from the insurance plan for certain medical services.
• is Medicare Advantage better than traditional Medicare? the best option depends on individual needs and preferences, considering factors like cost, coverage, and access to providers.
• what is CMS doing to address concerns about medicare Advantage? CMS is conducting more rigorous audits and exploring payment model adjustments to address issues like upcoding and overpayments.
• What role will technology play in the future of Medicare Advantage? Telehealth and remote patient monitoring are expected to become more prevalent, potentially improving access and reducing costs.
• How can beneficiaries ensure they choose the right Medicare Advantage plan? Carefully review network details, coverage, and prior authorization requirements before enrolling.

What are your thoughts on the future of Medicare Advantage? Share your comments below!

## Summary of the Text: Medicare Advantage Oversight & Reforms

Medicare Advantage (MA) plans have become a popular choice for millions of seniors and individuals with disabilities, offering an choice to customary Original Medicare. However,concerns surrounding Medicare Advantage payment accuracy have been escalating,prompting increased scrutiny from regulators and a renewed commitment to reform from the Biden-Harris Management. Secretary of Health and Human Services (HHS) Xavier Becerra recently reaffirmed this dedication, outlining steps to address systemic issues impacting the fairness and sustainability of the MA program. This article delves into the specifics of these reforms, thier potential impact, and what stakeholders – including beneficiaries, providers, and MA organizations – need to know.

The Core of the Problem: risk adjustment & Coding Practices

The foundation of the issue lies within the risk adjustment process. Medicare Advantage risk scores are calculated based on a beneficiary’s health status,using diagnosis codes submitted by healthcare providers. These scores determine the payments MA plans receive from the Centers for Medicare & Medicaid Services (CMS). Higher risk scores equate to higher payments, intended to cover the costs of caring for sicker individuals.

Though, investigations and audits have revealed a pattern of inaccurate coding and upcoding by some MA plans.

* Upcoding: Submitting codes for diagnoses that are more severe or complex then the actual condition.

* Diagnosis Coding Intensity: A higher frequency of coding for certain conditions compared to fee-for-service Medicare.

* Retrospective Chart Review: Plans reviewing charts after care is delivered to identify and add diagnoses, potentially inflating risk scores.

This leads to overpayments to MA plans, diverting resources that could be used to improve care or lower premiums for beneficiaries. The problem isn’t universal,but widespread enough to warrant critically important intervention. Terms like “Medicare Advantage fraud” and “Medicare Advantage abuse” are increasingly used in discussions surrounding these practices.

Secretary Becerra’s Reform Agenda: key Initiatives

Secretary Becerra’s commitment centers around several key initiatives designed to enhance Medicare Advantage oversight and ensure fair Medicare payments. These include:

1. Strengthened Audits & Enforcement: CMS is increasing the frequency and scope of audits of MA plans, focusing on risk adjustment data validation (RADV) and coding accuracy. Expect more rigorous reviews of medical records and a greater emphasis on identifying and recouping overpayments.
2. Revised Coding Guidelines: CMS is clarifying and strengthening coding guidelines to reduce ambiguity and minimize opportunities for inaccurate coding. This includes providing more specific guidance on documentation requirements and appropriate code selection. The focus is on aligning MA coding with fee-for-service Medicare coding.
3. Enhanced Data Validation: CMS is investing in advanced data analytics capabilities to identify patterns of potentially inaccurate coding and risk score manipulation. This includes comparing MA data to fee-for-service Medicare benchmarks and utilizing artificial intelligence (AI) to detect anomalies.
4. Increased Clarity: CMS is committed to increasing transparency in the MA program, making more data publicly available on plan performance, risk scores, and audit findings. This will empower beneficiaries and stakeholders to make more informed decisions.
5. Proposed Rulemaking (2024): The proposed rule released in 2024 outlines significant changes to the Medicare Advantage risk adjustment methodology, aiming to normalize coding patterns and reduce the incentive for upcoding. This includes phasing in a more accurate methodology for calculating risk scores.

Impact on Stakeholders: What to Expect

These reforms will have a ripple effect across the healthcare landscape.

* Medicare Advantage Organizations: MA plans will face increased scrutiny and potentially reduced payments if audits reveal inaccurate coding practices.They will need to invest in robust compliance programs and ensure their coding staff are adequately trained. Expect a greater emphasis on compliance with CMS regulations.

* Healthcare Providers: Providers will need to ensure their documentation accurately reflects the patient’s health status and supports the diagnoses submitted by MA plans. They may also be asked to participate in chart reviews and provide documentation to support risk scores. Understanding Medicare Advantage provider guidelines is crucial.

* Beneficiaries: While the immediate impact on beneficiaries may not be directly visible, the long-term goal is to ensure the sustainability of the MA program and protect benefits. Accurate payments will help ensure plans can continue to offer affordable coverage and access to quality care. beneficiaries should be aware of their rights and report any concerns about their care or coverage. Resources like the Medicare.gov website and 1-800-MEDICARE are valuable.

Real-World Example: The RADV Audit Focus

CMS has significantly increased its focus on RADV audits. In recent years, these audits have uncovered ample overpayments to MA plans. For example, a 2023 audit of several large MA organizations resulted in the identification of over $500 million in overpayments due to inaccurate coding. This demonstrates the potential financial impact of inaccurate risk scores and the importance of robust compliance programs. The audit process involves a detailed review of medical records to verify the accuracy of diagnoses submitted by the plans.

Benefits of Improved Payment Accuracy

correcting these issues isn’t just about financial accountability; it’s about improving the entire Medicare Advantage system.

* Fairer Competition: Leveling the playing field between MA plans and Original Medicare.

* Sustainable Program: Ensuring the long-term financial stability of the MA program.

* improved quality of Care: Redirecting resources towards patient care and quality improvement initiatives.

* Reduced Premiums: Potentially lowering premiums for beneficiaries.

* Enhanced Trust: Restoring trust in the MA program among beneficiaries and stakeholders.

Practical Tips for MA Organizations & Providers

To navigate these changes effectively, MA organizations and providers should:

* Invest in Coding Education: Provide ongoing training for coding staff on accurate coding practices and CMS guidelines.

* Strengthen Compliance Programs: Implement robust compliance programs to detect and prevent inaccurate coding.

* Improve Documentation: Ensure medical records are complete, accurate, and support the diagnoses submitted.

* stay Informed: Keep abreast of the latest CMS guidance and regulations.

* Proactive Audits: Conduct internal audits to identify and address potential coding errors.

* Utilize technology: Leverage technology solutions to automate coding processes and improve accuracy.

Looking Ahead: The Future of Medicare Advantage

The reforms spearheaded by Secretary Becerra represent a significant step towards ensuring the integrity and sustainability of the medicare Advantage program. While challenges remain, the commitment to Medicare Advantage payment reform is clear.Ongoing monitoring,data analysis,and collaboration between CMS,MA plans,and providers will be crucial to achieving lasting improvements and ensuring that the MA program continues to serve the needs of millions of Americans. The focus on Medicare Advantage quality ratings will also likely increase as CMS seeks to tie payments to value and outcomes.